tag:blogger.com,1999:blog-5530332534318660062017-09-07T16:05:28.457-07:00Dr. Stu's Blog. I am delighted you are here and hope you find my insights enlightening. Welcome to DR. STU'S BLOG. Along with my podcast at www.drstuspodcast.com it is here that I post my thoughts on a variety of topics on the birthing world. Advocacy for true informed consent and respect for individual autonomy are the basis for the musings you will read here. I hope you enjoy while you learn and I encourage you to comment. Please check out www.birthinginstincts.com for information on home birthing with an obstetrician and my latest news and updates. Stuart Fischbeinnoreply@blogger.comBlogger208125tag:blogger.com,1999:blog-553033253431866006.post-53265088383654744962014-03-30T18:59:00.002-07:002014-03-30T19:01:41.037-07:00Time to upgrade! Greetings to all of you who have loyally supported me on <a href="http://www.supportdrfischbein.blogspot.com/" target="_blank">this blog</a> and at <a href="http://supportdfischbein.com/">supportdfischbein.com</a>. I was encouraged by so many of you to modernize and consolidate a lot of my internet activities and I finally listened. I plan to continue blogging on relevant topics and entertain and inform&nbsp;on<br /><a href="http://www.drstuspodcast.com/" target="_blank">Dr Stu's&nbsp;podcast</a> as well as post all sorts of events and news on my new <a href="https://www.facebook.com/DrStuartFischbein?ref=hl" target="_blank">Facebook page</a>. Of course, the <a href="http://www.fearlesspregnancy.net/" target="_blank">Fearless Pregnancy</a> site where you can purchase my book is still there, too. All of these are linked through my completely revamp web site,&nbsp;<a href="http://www.birthinginstincts.com/" target="_blank">Birthing Instincts with Dr. Stu</a>,&nbsp;where you can read and learn about home birthing options including VBAC, breech and twin deliveries. There is also a current events page which lists upcoming seminars and lectures and gatherings. I am still at 3 locations including my Century City office, my Thousand Oaks office and the <a href="http://www.birthsanctuary.com/" target="_blank">Sanctuary Birth and Family Wellness Center</a>. Please check out all these sites and&nbsp;give them likes and stars and shares. According to my web guru, Renee, this blog site will remain up but future blogs and such will be posted on the new web site. See you over there. Warmly Dr. Stu<br /><br /><div align="center"><a href="http://www.birthinginstincts.com/">www.birthinginstincts.com</a>﻿</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-AH0Qs3FMEbc/UzjLwJV-uGI/AAAAAAAAAGM/ptsRHnFCHMc/s1600/Birthing+Instincts+New+Logo.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-AH0Qs3FMEbc/UzjLwJV-uGI/AAAAAAAAAGM/ptsRHnFCHMc/s1600/Birthing+Instincts+New+Logo.jpg" /></a></div><br /><br />Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com1tag:blogger.com,1999:blog-553033253431866006.post-19524006237817258822014-01-29T11:09:00.001-08:002014-01-29T11:13:58.328-08:00The Hazmat Birth<br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><br /><span style="font-family: Calibri;"><br /><span style="mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"><br /><o:p><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;">On the header of my blog are a few of my favorite historical quotes. I think my favorite has become Albert Camus’, “The Welfare of humanity is always the alibi of tyrants!” Fear is the easiest way to manipulate. And claiming safety is a perfect way to shut down any discussion. It’s good for you. It’s safer for the children. You don’t want to put your baby in danger, do you? We live in a world where ACOG admits that 2/3’s of its guidelines are not based on good scientific evidence. Yet they put them out anyway. In my world, on a daily basis, I am told directly or from print media about manipulation of women through skewed or even overtly false information. When it comes to pregnancy the bowing to the false god of safety has become the standard. Your baby is too big. Your baby is too small. Your pelvis is inadequate. The head is smaller than the shoulders which might get stuck. The fluid is decreasing. The cord is around the neck. You are 3 days overdue and your placenta is getting weak. VBAC is too dangerous. Your breech baby’s head might get stuck. Hospitals are safer. Induction is easy. Cesarean sections are routine.<o:p></o:p></div><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;">Then there is the mockery of choosing an alternative to the fear based standard birthing world. Home delivery is for pizza! Having your baby at home is like driving your child without a seatbelt (This is the latest flippant simile from a doctor in Australia. Which, by the way, was how my generation grew up and I don’t recall massive death on the highway). Or as Jim Gaffigan, the comedian, quips, “when I told my friends we were having a home birth they said, Yeah, we were going to do that but we wanted our baby to live!”. Choosing a home birth is selfish! Why would you pick a lesser trained midwife? How would you feel when something goes wrong!<o:p></o:p></div><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;">Ah, the something goes wrong theory of birth. Perfectly understandable in today’s fear based, litigious world. Risk management is something we all do every day. As individuals we just don’t have departments staffed with lawyers to do our personal risk management. Even if you could afford one can you imagine your life with every decision being scrutinized for safety and risk? Susie, you are not allowed to have that chocolate chip cookie because we have calculated that the risk/benefit ratio is adverse to your long term health and the viability of your family unit. Laughable? Far-fetched? Maybe, but this is the climate of the standard medicalized world we now live in. You cannot eat in labor because there is a 1/100,000 chance you might aspirate in an emergency. You must have an IV just in case. Please sign these consent forms about surgery and death after your next contraction. Sorry, hospital policy says you have to wear those belts continuously. <o:p></o:p></div><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;">This past week I came upon a top secret correspondence from a local hospital that read something like this: <i style="mso-bidi-font-style: normal;"><span style="font-size: 10pt; line-height: 115%;">“The OBGYN </span></i><i style="mso-bidi-font-style: normal;"><span style="color: black; font-family: &quot;Arial&quot;,&quot;sans-serif&quot;; font-size: 10pt; line-height: 115%;">Department and the Infection Control Division would like to remind you that <b id="yui_3_13_0_ym1_1_1391012716339_19577">eye protection (e.g. glasses, goggles) and a face mask are required</b> for all providers participating in a delivery.&nbsp; We thank you for your cooperation with this important safety issue.</span>” </i><span style="color: black; font-family: &quot;Arial&quot;,&quot;sans-serif&quot;; font-size: 10pt; line-height: 115%;"><span style="mso-spacerun: yes;">&nbsp;</span></span><span style="color: black; font-size: 10pt; line-height: 115%; mso-bidi-font-family: Arial;"><span style="font-size: small;">The last sentence is the sinister one. Putting that tagline on anything gives it the appearance of concern and reasonableness.</span> </span><span style="color: black; mso-bidi-font-family: Arial;">This may seem like a small thing but its insidious message is a continuation of the threat to all of us who value individual autonomy and see vaginal birth as something beautiful. This hospital, likely complying with some edict from some committee or oversight organization and almost certainly without a single adverse event in their institution, has turned the birth of a baby into a hazmat situation. My call to the author of this correspondence for clarification went unanswered. For those who have actually</span><span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Arial; mso-hansi-font-family: Calibri;"> attended an un-medicated birth, a home birth or a water birth, can you imagine what the mother must think if she were to look down at a goggled and masked face catching her baby? I understand for an unscreened mother wearing protection would be a reasonable choice. But most women are screened and, unless there has been a series of incidents, universally requiring this garb is not about safety. It is about protecting the institution from liability. Plausible deniability should a worker catch something who was not wearing the hazmat protection hospital policy required. The risk managers are just doing their job. However, I believe minimizing risk must be weighed against common sense and personal choice in a free society. Sadly, common sense is losing and will continue to do so until the masses lose enough services or are inconvenienced enough that finally tort reform becomes a hot political topic.<o:p></o:p></span></div><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Arial; mso-hansi-font-family: Calibri;">Why have they come forth with this new rule now would be a logical question. Has there been some epidemic of exposures? I mean, vaginal birth without mask and goggles has been going on for millennia. No, it’s simply a symptom of the micromanaged and over-regulated reality we are now living in. I also just read an editorial about getting rid of the doctor’s white coat. Why now? Has there been an epidemic of disease spread by the hospital lab coat? Changing dirty coats makes good sense but banning them? Will the next suggestion be changing clothes between hospital wards, between rooms? And why won’t your own clothes be carriers of bad humours and thus need to be banned. And I can tell you that wearing scrubs from home and all day and night from the ward, to the call room to the cafeteria does not sound exactly hygienic. Wearing disposable gown and gloves makes sense in an infectious disease setting but in the maternity ward, really? So the why now question is really that someone somewhere just thought it up in response to usually an isolated incident. There are legions of administrative personnel whose job it is to try to diminish risk. The foolishness is they believe they actually can in every case no matter what the consequences down the road. Their job is to protect their job and their institution and their tyranny is always justified by safety.<o:p></o:p></span></div><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="color: black; mso-ascii-font-family: Calibri; mso-bidi-font-family: Arial; mso-hansi-font-family: Calibri;">There are two realities in the birthing world as I see it. One is fear based, often absurd, seeing pregnancy as illness, believing that interventions make benefit greater than risk and using safety as a canard for control. The other is trusting of nature, understanding of the imperfections of life and looking at pregnancy as wellness and a normal function of the female body. I have lived in both worlds and have a unique perspective. The first is uncomfortable and often riddled with self-deceit cloaked in cognitive dissonance. The latter is my choice and I try to be a vanguard for it. This past week I had the good fortune to attend a beautiful home VBAC in the hostile birth world of Santa Barbara</span><span style="mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"> and an inspirational water birth in Beverly Hills. I wore a t-shirt and sweat pants and was goggle-less and mask-less and I am delighted to report I am well and happy.<span style="mso-spacerun: yes;">&nbsp; </span></span></div><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;"></span>&nbsp;</div><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="mso-ascii-font-family: Calibri; mso-hansi-font-family: Calibri;">All good things, Dr. Stu<o:p></o:p></span></div><span style="font-family: Times New Roman;"> </span></o:p>&nbsp;</span>&nbsp;</span>&nbsp;</div>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com3tag:blogger.com,1999:blog-553033253431866006.post-7604378534871062212013-11-17T10:32:00.002-08:002013-11-20T08:59:05.466-08:00Home Birth & Apgar Scores in the AJOG October 2013, some clarity.<br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">In the October 2013 issue of the American Journal of Obstetrics &amp; Gynecology (AJOG, also known as the Gray Journal) there are two “research” articles discussing outcomes related to birth setting. In today’s blog I take a critical look at both of them so if asked about them by a prospective client you can give a salient response. Since science has been corrupted by money and ideology it is difficult to know what to believe these days making reliance on common sense and clarity of intent that much more important.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">The first article begins on page 323 and is titled, “<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>Apgar Score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting</u></i></b>”. This ominously titled article is authored by Amos Grunebaum, MD out of Cornell University with multiple co-authors including Frank Chervenak, MD who we all know to be fervently biased against home birthing. In a previous blog I have been critical of the authors of this article for their deviation from scientific norms by promoting their paper through an uncontested press release more than a month prior to its publication. Thus, headlines received prior to any critical review. Let’s take a look at the data and methodology of this study and then analyze their conclusions.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">The stated objective is to examine the occurrence of 5-minute Apgar scores of 0 and seizures or serious neurologic dysfunction for 4 groups by birth setting and birth attendant (hospital physician, hospital midwife, birth center midwife, and home midwife) in the United States from 2007-2010. They used birth certificate data files from the U.S. Centers for Disease Control’s National Center for Health Statistics for singleton newborns &gt;37 weeks and &gt;2500 grams.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">In order to trust the results of any study we must first trust the information upon which the study is based. A retrospective study of birth certificate records, especially as used in this study, is ripe with unreliability. A simple example is the inability to determine precisely who attended a birth as the signature on the record does not mean that practitioner was actually there. I have signed birth and death certificates in my career for patients I did not care for simply because I was the physician on call and was asked to do so by the hospital staff. In 2003 the standard Certificate of Live Birth was upgraded to include the location of birth as hospital, birth center, or home. And it was further specified as accidental, intended, or unknown if intended. In 2008, only 27 states were using this upgraded form yet the Grunebaum study admits to using all U.S. births from 2007-2010 that met their inclusion criteria of &gt;37 weeks and &gt;2500 grams (of the 16,693,978 births they included 13,891,274). The second study I will discuss calls this methodology into question as their use of the more accurate revised form had them exclude nearly 50% of American births in the year 2008 alone. To summarize, birth certificate information is notoriously unreliable and often does not differentiate whether the birth was planned or unplanned, attended or unattended. Yes, someone has to sign it but it does not mean the doctor or midwife signing actually attended. <o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">The authors then rely on the 97.5% of states (?) that had collected data on the presence or absence of neonatal seizures or serious neurologic dysfunction in their birth certificates. I would question the reliability and collection methods of this data. The definition of a neonatal seizure is seizures occurring in the first month of life. Birth certificate data is usually filled out in the first couple days of life. I am not sure how the authors then used this data responsibly. Also, it would be important to know long term outcomes of the neonates who experience seizures or serious neurologic dysfunction and how that correlates to lifelong disability. This study does not clarify this endpoint.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">The term relative risk (RR) is used in this study to emphasize their conclusion that homebirth attended by a midwife has an overall 10.55 RR of a 5 minute 0 Apgar score. The RR is slightly higher in primips than in multips for all categories but RR can be quite misleading especially in the headline of a press release which was their intention, I believe. The overall risk in this study of a 5 minute Apgar score of 0 in the hospital attended by a physician was 1.6/10,000 births. For home births with a midwife it was 1.63/1,000. While this is a 10-fold increase it is still rare when you consider all the other risks of birth. It is purposeful deception to use statistics selectively in this way. Especially when they conclude that all obstetric practitioners must disclose this information to all pregnant women who express an interest in out-of-hospital birthing. “Surprisingly”, this article concludes with a recommendation that concurs with an article written last year by Dr. Chervenak on the professional responsibility of physicians to recommend against planned out-of-hospital births to women who express an interest in it. Amazing that based on a risk of .163% of a 5-minute Apgar of 0 doctors are told to advise against home birth but a 33% risk of surgical birth is no problem. A higher risk of infection, breast feeding issues, psychological trauma, mother-baby separation, induction/augmentation are not reasons to warn mothers against hospital birthing? The skewing of data to funnel women down the medical path is without shame. What more can I say?<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">Well, on this article there is one more glaring point to make. I could not find anywhere in this article a distinction between a live born newborn with a 5-minute Apgar of 0 and a stillborn. If a woman at term was diagnosed with an intrauterine fetal demise at term and chose to have her baby at home would that count as a 0 Apgar at 5 minutes? Finally, I have spent more than 27 years working in hospitals with NICU teams. When a baby is born with a very low or zero Apgar at 1 minute it is pretty much standard of care for the NICU team to rush in and perform their initial magic of resuscitation. Even if the baby were to be allowed to expire at 30 minutes or was to be revived only to die hours or days later the Apgar score at 5 minutes would not be a 0!! I would submit that the risk of 0.16/1000 for a 0 Apgar at 5 minutes in the hospital setting as quoted in the article is artificially low. And if this reasoning sounds logical then the entire premise of using the 5-minute Apgar score as a marker of quality of care by practitioner or location is undermined and serves to fit the Chervenak model of selective ethics! Maybe it would be professionally responsible for physicians to tell their patients that!</span><br /><span style="font-family: Calibri;"></span><br /><span style="font-family: Calibri;">(Please see my comments following this blog)</span><span style="font-family: Calibri;"><br /></span></div><div class="MsoNormal" style="margin: 0in 0in 10pt;"></div><span style="font-family: Calibri;"><br /></span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"></div><span style="font-family: Calibri;"><br /></span><div class="MsoNormal" style="margin: 0in 0in 10pt;"><div class="MsoNormal" style="margin: 0in 0in 10pt;"><!--4--><!--4--><span style="font-family: Calibri;"><span style="font-family: Times New Roman;"> </span></span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">The second article on page 325 in the October 2013 issue of the AJOG is titled, “<b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><u>Selected perinatal outcomes associated with planned home births in the United States</u></i></b>” by Y.W.Cheng, MD et al, from UCSF. This was a retrospective study, also, of term singleton live births in the U.S. in 2008. Of the over 4,000,000 births that year, 2,081,753 met the study criteria of using the 2003 birth certificate revision discussed above. Of these births 0.58% were planned home births. They found that planned home births had a higher rate of 5-minute Apgar score&nbsp;less than or equal to 4 with a RR of 1.87 (3.7/1000 vs. 2.4/1000) and a RR of 3.08 for neonatal seizure (6/10,000 vs. 2/10,000). They also concluded that women with planned home birth had fewer interventions such as operative vaginal delivery and induction/augmentation. They also broke down planned home births by CNMs or “other” midwives.<o:p></o:p></span></div><span style="font-family: Calibri;"><span style="font-family: Times New Roman;"> </span></span></div></div><span style="font-family: Calibri;"></span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Times New Roman;"> </span></div></div><span style="font-family: Times New Roman;"> </span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">Their findings and the presentation of their data in style seemed much more neutral and unbiased. For instance, they do state that infants born to women with a planned home birth are more likely to have a neonatal seizure (6 vs. 2 per 10,000, still a small number) but also say that NICU admission was lower among infants of planned home birth (RR 0.23). They did emphasize that outcomes for homebirths with CNMs did not differ significantly from hospital births but that with “other” midwives the risks were greater. However, I could not find a definition for “other” midwives in the article.<o:p></o:p></span></div><br /><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">I found the self-reflection and critiquing of their own research to be honest and refreshing in stark contrast to the first article’s air of certainty which feels like smugness to me (my bias!). Cheng, et al admit their study has limitations. “As a retrospective study, it may have included confounding or missing data that could potentially bias our findings.” They go on to say, “….administrative data, such as birth certificate data, may contain inaccurate information.” Now isn’t that refreshing to hear from a researcher? They also honestly admit they could not identify or differentiate women who planned a home birth but who were transferred to hospitals which they admit occurs in 10-15% of planned home births <span style="mso-spacerun: yes;">&nbsp;</span>(Notice the use of 10-15% rather than the skewed numbers of up to 47% Dr. Chervenak used in a previous opinion piece last year). This could elevate the risks at home but they admit they cannot be sure. Finally, Dr. Cheng concludes, “Because of the complex tradeoff between maternal benefits and neonatal risk, women who contemplate location of birth should be fully informed about both sites”. <o:p></o:p><br /><span style="font-family: Times New Roman;"> </span><br /></span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">Here are 2 articles, side by side, both presenting a selected endpoint on the outcomes of term singleton births by location and practitioner. However, the difference in style and honesty is striking. The first article has a co-author with a deserved reputation for skewing his data to fit his ideology. While I cannot quantify his influence on his fellow co-authors I can use experience and common sense to recognize bias, selective data mining, intentional omissions&nbsp;and flaws in methodology and conclusions. It is important for all of us to look at research with a critical eye. Understand that relative risk is rendered far less meaningful when we are comparing a small number to a multiple of a small number. I must agree with Dr. Cheng. Once the sperm and egg unite there are risks assumed. True, not skewed, informed consent must be given about all options. And respect for the individual is paramount for it is the essence of ethics to respect the autonomy of patient decision making and it cannot be expected that given the same information two people with differing life experiences will always reach the same conclusion. Finally, good science does not need to be preempted by a press release. I have been concerned of late that science is more and more being corrupted by money and ideology. While we may not prevent this we must remain aware of it and read critically and maintain a healthy skepticism. <span style="mso-spacerun: yes;">&nbsp;&nbsp;</span><o:p></o:p></span></div><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><span style="font-size: small;"><span style="font-family: Times New Roman;"> </span><br /></span></span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><span style="font-size: small;">Dr. Stu<o:p></o:p></span></span></div><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><span style="font-size: small;"><span style="font-family: Times New Roman;"> </span><br /></span></span><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><o:p><a href="http://www.drstuspodcast.com/" target="_blank"><span style="font-size: small;">www.drstuspodcast.com</span></a></o:p></span></div><span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><span style="font-family: Times New Roman; font-size: small;"> </span></span>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com10tag:blogger.com,1999:blog-553033253431866006.post-35260566373769527252013-09-17T08:33:00.003-07:002013-09-18T22:25:34.958-07:00We need a better way to dialogueThe American Journal of Obsterics &amp; Gynecology has recently published Dr. Chervenak's response to my letter to the editor which I wrote in response to his opinion piece against planned home birth. I have commented on this in a couple of blogs on this site (see November 2012). I even went so far as to put together a power point presentation breaking down his arguments and would be happy to debate him in an honest forum. My letter was published last April but the AJOG rules of LTE are very restrictive and I was limited to 400 words. In his rebuttal to me letter he continually sites that I did not prove what I said or that I lacked documentation or failed to provide supporting evidence. These tasks are pretty much impossible with 400 words. A fact I am sure Dr. Chervenak is aware since his rebuttal to me was allowed 641 words. This is the serious defect in our ability to communicate differing views to the powerful in academia and simply leads to childlike finger pointing and ego inflation without any real chance of clarity and honest dialogue. His reliance on studies, often ones in disrepute, skewing of data and denial of&nbsp;or failure to accept evidence and common sense contrary to his desired outcome of his opinion piece is a common thread in many of his thoughts and papers. I accept that he is a bright man with differing views than mine. My point is not to convince him of alternatives. My ideal is to present clarity over agreement so readers and my medical colleagues have the basis on which to make their own decision. <a href="http://www.azdhs.gov/als/midwife/documents/committee/additional-resources/ajog-planned-home-birth.pdf" target="_blank">Here is a link to his original article</a> (which might be password protected), my 400 word limit letter to he editor followed by his 641 word response. &nbsp;Lastly, kudos to the American Journal for publishing a midwife's response, as well, which I have also posted.<br /><br /><strong>Dr, Fischbein's LTE</strong>:<br />In a recent opinion piece, “Planned home birth: the professional responsibility response,” Chervenak et&nbsp;al<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00388-8/fulltext#bib1" id="cross-ref-bib1" name="back-bib1" style="text-decoration: none;" title=""><sup>1</sup></a> argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 points: patient safety, patient satisfaction, cost-effectiveness, and respect for women’s rights. “We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.”<br />Regarding patient safety, the authors say, “Maternal and fetal necessity for transport during labor is often impossible to predict.” Home birth women by definition are selected based on their health. They labor as nature intended without interventions. In experienced hands, transport is rarely “impossible” to predict. The authors state the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. The argument against home birth in the United States continues by presenting safety data from South Australia, a system that has no resemblance here.<br />The authors state, “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the&nbsp;number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs a hospital have cesarean section rates of 6% and 24%,<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00388-8/fulltext#bib2" id="cross-ref-bib2" name="back-bib2" style="text-decoration: none;" title=""><sup>2</sup></a> respectively. By&nbsp;that standard the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible.<br />Regarding patient satisfaction, the authors assume the high rates of transport undercut the raison d’être of planned home birth. A Dutch study from 2008 showing persistent levels of&nbsp;frustration for up to 3 years in 17% of transported women is cited.<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00388-8/fulltext#bib3" id="cross-ref-bib3" name="back-bib3" style="text-decoration: none;" title=""><sup>3</sup></a> That implies an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of US women with&nbsp;successful home vs hospital births. I disagree with the solution of supporting “homebirth-like” environments in the hospital setting.<br />Minimal savings in cost comparison data from Britain are cited, vs US cost comparisons. The cost of a typical home birth in the United States is about 35% of that in hospitals. Savings over a cesarean birth approach 80%.<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00388-8/fulltext#bib4" id="cross-ref-bib4" name="back-bib4" style="text-decoration: none;" title=""><sup>4</sup></a> When cesarean section rates approaching 35%<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00388-8/fulltext#bib5" id="cross-ref-bib5" name="back-bib5" style="text-decoration: none;" title=""><sup>5</sup></a> are factored in, the savings is even more significant.<br />Regarding women’s rights, the authors avoid using the beneficence-based model of ethics which, as with vaginal birth&nbsp;after cesarean, supports a woman’s reasonable choice.<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00388-8/fulltext#bib6" id="cross-ref-bib6" name="back-bib6" style="text-decoration: none;" title=""><sup>6</sup></a> Instead it is stated, “From the perspective of the professional responsibility model, insistence on implementing the unconstrained rights of pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine.” But home birth advocates do&nbsp;not support unconstrained rights or rights-based reductionism.<br /><br /><br /><strong>Dr. Chervenak's Rebuttal:</strong><br />Dr Fischbein claims that our criticism of planned home birth from the perspective of the professional responsibility of obstetricians does not succeed. Ethical analysis of planned home birth, like ethical analysis of all topics in obstetric and medical ethics, should be both evidence-based and argument-based.1<br />On the topic of patient safety, Dr Fischbein states that the need for transport can be predicted in “experienced hands” but provides no documentation for this claim. The Birthplace in England study reported on transport rates as high as 45%.2 Dr Fischbein bears the burden of proof to identify evidence-based criteria for the reliable prediction of the need for transport and fails altogether to meet this professional obligation. He then states that “pain relief and prolonged labor” do not indicate unsafe clinical conditions, again without supporting documentation. The claim that the experience in another country does not apply in the United States requires Dr Fischbein to demonstrate the disanalogy, which he does not do.<br />Dr Fischbein states that a cesarean delivery rate in the hospital setting of 24% results in an unacceptable increased morbidity when compared to the out-of-hospital cesarean delivery rate of 6%. As applied to planned home birth, the claim is absurd, inasmuch as cesarean deliveries are not performed in the home setting. Even if the comparison were not absurd, simply reporting the rates of a procedure in the absence of outcomes data does not count as evidence-based reasoning. Worse, the paper that Dr Fischbein cites provides outcomes data on care in birth centers.3 Planned birth at home, the focus of our paper, is not planned birth at a birth center. The outcomes in the latter cannot be represented as the outcomes of the former. The disanalogy is obvious–and egregious.<br />Regarding patient satisfaction, our point in citing the Dutch experience was–and remains–that in one of the most highly developed home birth systems in the world there are significant rates of failure to achieve patient satisfaction. A dissatisfaction rate of 17% is high per se and therefore intrinsically clinically significant. Asserting the obvious corollary of 83% satisfaction should be read for what it is: an attempt to distract the reader from a substantial, documented problem with planned home birth. Dr Fischbein then states that he disagrees with national efforts to improve the homelike setting of hospital delivery without any supporting reasons. Asserting conclusions in the absence of supporting reasons is what Plato–long ago–had Socrates in the Dialogues characterize as “mere opinion,” which never counts as argument-based reasoning.<br />As to cost-effectiveness, we emphasized that analyzing the cost of home birth by comparing charges for home birth to charges for hospital birth is incomplete and therefore potentially misleading. Dr Fischbein’s invocation of relative costs of vaginal vs cesarean delivery does not address relative overall cost. His claims about comparative cost are therefore incomplete and misleading.<br />As to women’s rights, Dr Fischbein invokes the ethical analysis of vaginal birth after cesarean delivery by Charles,4 who argues that the autonomy of pregnant women is justifiably constrained by the professional judgment of obstetricians about what is medically reasonable.4 Dr Fischbein neglects to inform his reader that Charles4 bases her argument explicitly on our approach to obstetric ethics. Having rejected our approach (albeit without any supporting argument), Dr Fischbein invokes a paper based on it. Dr Fischbein succeeds in both deceiving his reader and violating the principle of noncontradiction. This principle forbids simultaneously holding a proposition and its denial to be true and is therefore a disabling mistake in both evidence-based and argument-based reasoning.<br />Planned home birth is a serious topic in obstetric ethics. Judgments about its ethical acceptability must therefore be deliberative–explicitly appealing to the results of evidence-based and argument-based reasoning.5 Dr Fischbein’s letter does neither and therefore makes no serious contribution to how obstetricians should understand their professional responsibility concerning planned home birth.<br /><br /><div id="salutation"><strong>Midwife's Letter To the Editors:</strong></div>The clinical opinion related to planned home birth by Chervenak et&nbsp;al<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00487-0/fulltext#bib1" id="cross-ref-bib1" name="back-bib1" style="text-decoration: none;" title=""><sup>1</sup></a> requires a midwifery response.<br />Home birth is a complex choice that includes the rights of women over their bodies; these rights do not go away because health professionals or governments ban them. The authors suggest that women’s rights should be superseded by the clinician’s obligation to protect the pregnant woman and the “fetal, neonatal patient.” This paternalistic discourse privileges the baby’s rights over that of the woman’s. Any risk to the&nbsp;baby’s health dominates with woman’s rights and risks to the woman’s health subjugated. A civilized society considers women to be more than just vessels to grow babies. To postulate that women’s opinions, concerns, and intelligent consideration for their own health and their baby’s health should be superseded by an obstetrician is unacceptable. The argument by Chervenak et al<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00487-0/fulltext#bib1" id="cross-ref-bib1" name="back-bib1" style="text-decoration: none;" title=""><sup>1</sup></a> that a woman’s right to make decisions and control what happens to her body is a “purely contractual model” and “rights reductionism” is contrary to the human rights movement. The United States, as a signatory to the Convention for Elimination of Discrimination against Women, recognizes this important principle.<a class="cross-ref" href="http://www.ajog.org/article/S0002-9378(13)00487-0/fulltext#bib2" id="cross-ref-bib2" name="back-bib2" style="text-decoration: none;" title=""><sup>2</sup></a><br />The authors assume that hospital birth and obstetric intervention will confer improved safety and better outcomes but the US cesarean section rate has increased far more than its rate of decreasing perinatal mortality and the United States is one of the few developed countries with increasing maternal mortality, yet&nbsp;Caution needs to be taken when discussing safety and safer care; until such a time as there is no mortality or morbidity associated with childbirth, no one can promise complete safety regardless of birth setting.Women worldwide cite the loss of personal autonomy and&nbsp;increasing use of interventions in hospital birth as unsafe for both them and their babies and see this as an unacceptable risk. When this is put in the context of comparable perinatal outcomes for the baby many women consider that hospital birth provides an increased risk with few benefits for them.<br />If women are supported, listened to, and provided with information they will make decisions based on the best outcome for them and their baby. Health professionals providing maternity services should be seeking to provide safe, woman-centered care for all women regardless of where they choose to birth.<br /><br />Wouldn't it be great if those on high in academia with opposing views were willing to come and speak at, say, the international breech conference or a gathering of homebirth advocates? Wouldn't it&nbsp;be great if academia invited those of us with legitimate alternate points of view to speak at their conferences. The dialogue would be amazing. I have heard all of their arguments but I can tell you that almost none of the residents and students have ever heard any of mine. Sadly, this tit for tat silliness through edited letters that take months to publish and can be quite time consuming for those of us not on academic salary is a poor way to communicate. What happens mostly is what ACOG district VIII is doing next week in Hawaii by having a lecture on home birth at their conference given by Amy Tuteur, a&nbsp;notorious anti-midwife, anti- homebirth blogger. C'mon academia, you can do better. We have so many outstanding intellects and actual practitioners of the trade who are willing to have courteous dialogue in real time. <br /><br /><a href="http://www.blogger.com/null" name="cebib0010"><!----><!----></a><br /><div id="back-to-article-outline-link">Dr Stu</div>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com5tag:blogger.com,1999:blog-553033253431866006.post-14419079803281490472013-09-05T12:19:00.000-07:002013-09-05T13:53:31.149-07:00From their fruits ye shall know them<br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">Today is the Jewish New Year, Rosh Hashana. It is a time for renewal, a time for family and, soon, will come a time to atone for one’s sins on Yom Kippur. In order to really ask forgiveness for a sin we must first recognize that we have sinned. Once recognized, moral teaching would hope that we accept self-reproach. Penitence is showing remorse for having done wrong. Only to a penitent man can come redemption, and a man redeemed will experience happiness and joy in work and life much more readily.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">“It’s not who we are but what we do that defines us”, so says the superhero in a recent Batman movie. And while not all movies contain such wisdom, on occasion they do. Good men and women, loving to their children and respectful of their parents, can sometimes do bad things. It does not mean they are bad people. For example, a businessman may be a great father and donate time and money to local charities but end up going to jail for embezzlement a la Bernie Madoff. Which leads me to my point; how does a good person become a bad doctor? How has a hospital become more of a danger to birth than a benefit? Specifically, how have the practitioners of medicine evolved from the noble, “first do no harm”, to embrace a culture of expediency, cowardice and fear. And how has the hospital machinery, what is considered the norm today,&nbsp;really&nbsp;performed when it comes to outcomes over the last generation?<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">If you have followed my writings, talks, blogs and more recently my podcasts you will know the answer to many&nbsp;of&nbsp;these questions. More than 50 years ago the takeover of medicine began by the profiteers who, by definition, looked at the business side of medicine as if it were an automobile factory. How to become more efficient? How to avoid liability? How to control costs? Essentially, how to control everything! But medicine is not automobiles. It’s people, individual people, often with life altering issues that don’t fit the assembly line thinking. It’s messy by the businessman’s standard. But rather than realize that, or maybe even despite realizing it, there was just too much money to be made and power to be had by taking it over. Lost in this was the lonely patient. And soon even the practitioner, the person actually&nbsp;doing the work,&nbsp;was just a cog in the machine. Initially, a very noisy cog but gradually the noisy cogs get “greased” and became what they once detested or they are beaten up and replaced by the system. Doctors either become a “part of the crew, part of the ship” (to ironically quote another Pirate story) or they were tossed overboard, sometimes metaphorically and sometimes literally. <o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">With the seeming inevitability of a government takeover of healthcare and the race to socialized medicine this metamorphosis will be complete. The designed impersonalization of the system frees any one or group of people from responsibility. And once an immense and monolithic entity is freed from any culpability it will always lead to corruption and tyranny. It will be like the current Internal Revenue Service scandal of oppression where no one is responsible and those that&nbsp;should be&nbsp;plead the Fifth Amendment and are never brought to task. However, unlike the IRS, those that seek the takeover of the health care system will sugar coat their motives under the disguise of “safety”. “The welfare of humanity is always the alibi of tyrants” was written by French Philosopher Albert Camus almost 60 years ago. Awareness of this mechanism is of utmost importance for it explains much about the fruit our system is baring.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">How is it that good, well-meaning people inside the system have let this happen and may even support it? It is human nature for members to want to be accepted in their group and for many it is their dominating psychological motivation. When the businessmen, lawyers, politicians and administrators who run health care now send out a message of how things are to be done, well, who are the nurses and doctors, dependent on the system for their livelihood, to complain? And so these good people who admittedly love their families and possibly regularly attend their church just easily surrender to EMR and to limited formularies and to restrictive policies like VBAC bans and mandatory lab tests and one size fits all lengthy admission forms and annual board recertification and silly mandatory human resource seminars. Need I go on? Policies and actions that put individual patient’s desire and rights off the radar screen if not dead last. Not only do the caregivers submit but they begin to defend their behavior as “standard of care”! They join committees and participate in this bureaucratic process so as to be accepted and “part of the crew…” Even when they know there are other options and evidence supported choices. I suspect that the administrators and their ilk know this, too. And in order to justify the correctness of their position they ridicule or ignore evidence to the contrary. This is called cognitive dissonance and I have written on this before. (“Safety or Cognitive Dissonance” May 27, 2012<span style="mso-spacerun: yes;">&nbsp; </span></span><a href="http://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.html"><span style="color: blue; font-family: Calibri;">http://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.html</span></a><span style="font-family: Calibri;"><span style="mso-spacerun: yes;"><a href="http://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.html" target="_blank">http://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.html </a>&nbsp; </span>)<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">The failure of good people to stand up on behalf of each individual family they care for may be practical but let’s not call it right. The good people that leave their home each day to drive to work at the local hospital do not say to themselves, “Let’s see what mischief I can cause today for some poor suffering patient” or “Let’s see how impersonal I can make our policy so that I limit the institution’s liability”. But somehow that is what happens each and every day for over 50 years in this profession. In 1970, the cesarean section rate in the United States was &lt; 6%, <span style="font-family: &quot;Calibri&quot;,&quot;sans-serif&quot;; line-height: 115%; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: &quot;Times New Roman&quot;; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;">In 1990 it was 22% and now in 2012 it is 32.8%. There has been little decline in the neonatal death rate between 1970 and 1990 and almost none in the last 23 years. Yet the cesarean section rate has gone up 500% since 1970</span></span><span style="font-family: Calibri;"> <!--6--></span>and over 50% in the last generation with no measurable benefit. Did something suddenly happen to an American woman’s pelvis in one generation? While some modifications of policies are all too slowly reappearing we still have archaic, often ridiculous policies affecting laboring mothers negatively. Some are restrictive movement, restrictive oral intake, standardized charting requirements leading to interruption of natural labor, 90% epidural rates, mother-baby separation and over testing for questionable indications often resulting from economic gain and fear. This fear comes, not so much in the mother, but emanating from the practitioner who endures the realities of the professional climate rather than speak out. A great proportion of women do not have fond memories of their birth process and many women will suffer lifelong emotional and physical trauma from unnecessary inductions and cesarean sections. Babies, too, do not benefit from what is so often considered standard care. Early induction or surgical birth leads to increase risks of lifelong health issues. Ubiquitous standardized policies of immediate vaccination, eye care in culture negative moms and interruption of bonding are for what benefit again? <!--6--></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">Courage is the rarest of good human traits. It is not courageous to stand up in front of a group and say what they want to hear. It is courageous to take a moral stand into the lion’s den. My colleagues are good people but they are not courageous. Those that purport to run healthcare, the businessmen, their lawyers and the politicians are worse because they disguise their motivation in the sheep’s clothing of safety. They have to know these outcomes are not what they should be. They have to know the policies they follow when it comes to birth are often dead wrong. How could a 33% cesarean section rate be acceptable to them. Why do they treat mothers and babies as two separate entities? There is so much reliable data that other options are reasonable. They do not respect the individual or the right of informed consent and refusal. And, quite frankly, in normal healthy mothers their statistics and outcomes are awful. Individuals are often good people. When they join organizations, however, they can become conflicted and end up doing bad things. The outcomes of groupthink are easily corrupted and rarely pure and morally upright. Just look at history. The fruits of the impersonal system of healthcare we call normal are rotting and&nbsp;subjugation to this model has&nbsp;not led us to higher ground. On this we should reflect and repent and the Jewish New Year can be an inspirational time to do so. We can redeem ourselves by&nbsp;doing better&nbsp;on behalf of our patients and our souls. Our acts are what define us. “From its fruit shall the tree be known.” (Matthew 7:16)</span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">Shana Tovah, Dr. Stu<o:p></o:p></span></div>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-73464047612836389812013-08-27T07:25:00.003-07:002013-08-27T07:26:27.991-07:00Student Intern ExperienceFor 2 months this summer I had a premed student spend 3 days a week with me as a student intern. I had a great time with Marybeth and it was a learning experience for both of us. What follows is a brief summary of her experience and I am hopeful that more students will follow in her footsteps. I look forward to the day when current medical students and possibly even obstetrical residents will desire to step out of the academic medical bubble and experience another way of doing things. Dr. F<br /><br /><br /><div id="yui_3_7_2_1_1377610370747_5931"><div dir="ltr" id="yui_3_7_2_1_1377610370747_5930" style="color: black; font-family: Verdana; font-size: 11px; line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;"><span id="yui_3_7_2_1_1377610370747_5929" style="background-color: transparent; font-family: Arial; font-size: 15px; vertical-align: baseline;">"<em>I started my internship hours on Wednesday, 18JUN13. &nbsp;I arrived at The Sanctuary Birth and Family Wellness Center for 1300 in order to do requisite confidentiality paperwork and got a brief familiarization with office procedures such as prepping files, keeping track of client due dates, etc. &nbsp;Dr. Fischbein had 4 clients scheduled for the day. &nbsp;I got to participate in 2 ultrasounds, both were 20 week anatomy scans and both families wanted to know the sex. &nbsp;One of his clients is pregnant with twins. &nbsp;After Dr Fischbein chatted with patients, he referred to me if I had any questions and gave my direct patient contact time. &nbsp;I also took a fundal height using a tape measure on the twin's mama's belly. &nbsp;Because one of his clients canceled, I used the most of my hours at the clinic to read up on the twin situation and review the chart to see if the twins were monochorionic and/or monoamnoitic or not. &nbsp;</em></span></div><br /><em></em><br /><div dir="ltr" id="yui_3_7_2_1_1377610370747_5938" style="color: black; font-family: Verdana; font-size: 11px; line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;"><span id="yui_3_7_2_1_1377610370747_5937" style="background-color: transparent; font-family: Arial; font-size: 15px; vertical-align: baseline;"><em>Dr Fischbein prefers to sit with patients in his office fully clothed first and discuss their concerns before they go to an exam room. &nbsp;He likes to take his time with patients. &nbsp;So we did another ultrasound, this time a vaginal one to try to get a gestational date because they are more accurate for crown rump length that early than the belly ultrasounds. &nbsp;It's was a struggling pregnancy and before the end of my internship it did result in a miscarriage. &nbsp;Then there were 3 pap smears with 3 CBCs and 3 breast exams. &nbsp;</em></span></div><br /><em></em><br /><div dir="ltr" id="yui_3_7_2_1_1377610370747_5940" style="color: black; font-family: Verdana; font-size: 11px; line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;"><span id="yui_3_7_2_1_1377610370747_5939" style="background-color: transparent; font-family: Arial; font-size: 15px; vertical-align: baseline;"><em>The internship continued in this fashion. In order to meet my first goal of learning about the birthing process, I attended on home visit with Dr. Fischbein, one homebirth, and one post-partum visit. &nbsp;The homebirth was very intense for me. &nbsp;Initially I just observed quietly while she labored and pushed in the birth pool. &nbsp;Occasionally the midwives asked me to fetch warm water for them and such. &nbsp;Dr. Fischbein mostly hung back on the couch so that the midwives could do their thing without him interfering as he is there for backup. &nbsp; This mama had been laboring for many hours and was getting tired so they called Dr. Fischbein into action. &nbsp;After mama did some solid pushing in the tub, on the birth stool, seated in her husbands lap, and in their bed, everyone agreed it was an ok time to help with some forceps. &nbsp;Dr. Fischbein always found a way to pull me in and give me lessons on things, so while mama was pushing from her own bed, she was at the edge with a foot up on my shoulder and I held her leg so I was right up close and personal with this birth. &nbsp;He first assessed the head by finding the sulcus because he told me you can only use forceps when baby is in certain positions, otherwise it is too dangerous. He explained the risks like bulldogging shoulders and dystocia to the mama and daddy. Once he determined baby was in a good position for what type of forceps he would be using, he numbed mama with some novocaine in case he ended up doing an episiotomy. &nbsp;I got to see him get the forceps in place, again right up close and personal with a foot on my shoulder and her leg in my hands, and with each contraction mama pushed, he wedged the forceps with baby out a little more, and I had a front row seat to all of this. &nbsp;He did end up doing the episiotomy, a quick clean cut which gave more room for the forceps and within seconds baby was out and on mama's chest and she had the drug free homebirth that she wanted after all. &nbsp;It was amazing. &nbsp;The cord stayed attached for quite awhile as it finished pulsing so that baby could get all her good oxygen and blood from there. &nbsp;The family had their time to be gentle and relax and the midwives went back to work with the rest of it, helping the placenta, etc, and then Dr. Fischbein was back in the game to repair the tear. &nbsp;He explained that sometimes mamas get tears along the sides from forceps but this mama luckily didn't. &nbsp;I held the spotlight while he repaired the cut. &nbsp;I'm not going to lie, it was a lot of blood. &nbsp;A lot of blood. &nbsp;Once he got done with the repair, it hardly looked like much had gone on down there at all. &nbsp;</em></span></div><br /><em></em><br /><div dir="ltr" style="color: black; font-family: Verdana; font-size: 11px; line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-family: Arial; font-size: 15px; vertical-align: baseline;"><em>Overall I participated in over 20 ultrasounds, some for pregnancy, some for fibroids, some for cysts. &nbsp;By the end of the internship, I was able to start making out images on my own. &nbsp;Like anything, it is its own language in a way, and you have to develop fluency in it. &nbsp;Ergo, I was easily able to meet my goal of learning how to use ultrasound as a diagnostic tool. &nbsp;</em></span></div><br /><em></em><br /><div dir="ltr" style="color: black; font-family: Verdana; font-size: 11px; line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-family: Arial; font-size: 15px; vertical-align: baseline;"><em>In order to achieve my third objective, like all the previous objectives, it depended upon what the patients presented. &nbsp;Nobody needed an external version and nobody ended up being a breech vaginal delivery. &nbsp;I did, however, do urine tests, which is really simple and just involved dipping a color-changing wand into the urine and comparing the results to the answer key if the urine had any protein or sugar in it. &nbsp;I also attended LE Leche gatherings and was able to assist pre-natal mamas in preparing for breastfeeding. &nbsp;One mama asked if drinking beer really helped to increase supply and I was able to provide her with sound, good guidance. &nbsp;It was pretty nice that Dr. Fischbein would just refer to me when any of his patients had breastfeeding questions.</em></span></div><br /><em></em><br /><div dir="ltr" id="yui_3_7_2_1_1377610370747_5942" style="color: black; font-family: Verdana; font-size: 11px; line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;"><span id="yui_3_7_2_1_1377610370747_5941" style="background-color: transparent; font-family: Arial; font-size: 15px; vertical-align: baseline;"><em>I enjoyed everything about this internship. &nbsp;It was an absolutely amazing experience. &nbsp;The only thing I really felt disappointed by was that I didn’t get to see more breech work or a breech delivery. I’m very grateful to SMC for having such an opportunity to design one’s own internship and incredibly grateful to Dr. Fischbein for patiently allowing me to walk in his shadow for two months. I am also amazed by how much I learned and did in just 2 short months with Dr. Fischbein. &nbsp;He was an incredible mentor.</em>"</span></div></div><br /><div id="slot_N"><div class="darla" hidefocus="" id="tgtN" tabindex="-1"></div></div>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-29003723974694868832013-08-26T22:18:00.001-07:002013-09-09T23:23:28.040-07:00VBAC is Normal<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-igPaIVritIo/Uhw2A_i59YI/AAAAAAAAAFA/8HGWEJToj-w/s1600/Beths+VBAC.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="212" src="http://2.bp.blogspot.com/-igPaIVritIo/Uhw2A_i59YI/AAAAAAAAAFA/8HGWEJToj-w/s320/Beths+VBAC.png" width="320" /></a></div><br />All you have to do is look at Beth's face to understand the miracle of normal birth. Baby Maiya, born by VBAC today at the Santa Clarita Birth Center in Newhall, CA. Keeping it positive. No other words necessary!&nbsp;Congratulations&nbsp;Beth &amp; Robert. Thank you Renee, Juli &amp; Victoria. &nbsp;Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-27111039693595922942013-08-21T08:12:00.000-07:002013-08-21T08:12:09.641-07:00Acceptance yes, but not Acquiescence!(Printed with permission)<br />Yesterday I flew to Minneapolis for a family gathering and to honor my father on his upcoming 93rd birthday. And, yesterday a lovely couple in southern California had their beautiful baby born breech....by cesarean section. <br /><br />Flashback to 10 days ago: I received a call from a couple living in San Diego about to have their first baby. Planning a home birth all along they discovered at 38 weeks their baby was in the breech position. Their midwives suggested many of the usual techniques such as chiropractic adjustment, acupuncture with moxi and position changes but to no avail. They were referred to a very nice doctor in the area who scheduled them for a cesarean section. They were never given the option of a vaginal breech birth. Typical of the home birthing culture they were well informed and looked into this option on their own via an internet search which is how I came to meet them. <br /><br />10 days ago they drove up to Los Angeles for a consultation. We talked for an hour and a half about options and discussed the current literature as well as risks and benefits of both cesarean and vaginal delivery. I gave them copies of Dr. Marek Glezerman's great review on the subject and did an exam and ultrasound to be sure she met the criteria necessary for a safe vaginal birth. Their baby was in the complete breech presentation, flexed head, 7+ pounds, normal anatomy and clinically generous pelvis. And, of course, they truly had the right "mental stuff". Perfect! And even better, they had family in nearby Thousand Oaks, California who were happy to allow them to stay and have their baby at home. So all we had to do was wait for labor to ensue. The only hiccup in the plan was that for months now I had a vacation with my daughter planned and so purposely did not take any regular clients at that time. But breech babies are determined late and, surprise, like many aspects of pregnancy they don't know there is a plan.<br /><br />So, they moved in to the sister's home and we all crossed our fingers. On the day before I was to leave she came to the office at 38 6/7 weeks announcing she probably passed her mucus plug (oh oh,&nbsp;we&nbsp;could see where this&nbsp;was going). We already knew there were no options&nbsp;she could find&nbsp;in San Diego and the only other&nbsp;breech supportive doctor&nbsp;in Los Angeles, a city of 4 million people, over 100 hospitals&nbsp;and 10 million in the whole metro area was not an option for this family.&nbsp;Two obstetricians in a city of that size who openly and willingly support the evidenced based option of selected vaginal breech delivery. One supporting home delivery and only one supporting hospital birth. Shameful! <br /><br />Aware of my travel plans, together, we came up with the backup plan of going back down to San Diego while I was&nbsp;away and if labor happened, well, that was baby's decision and they would have a cesarean section with the nice doctor they had met&nbsp;near home in&nbsp;familiar surroundings and&nbsp;close to&nbsp;their midwives. Sure enough, about 7 hours before I was to leave my cell phone rang to say she broke her bag of waters. "Clear fluid!", she proudly announced in her always optimistic and cheerful voice, "But feeling no contractions". We had a nice but brief talk in her car on the freeway back to San Diego. By sunrise she was being prepped for her cesarean and when I reached Denver to change planes I had a beautiful picture of her baby on my phone and a lovely message of thanks. A happy ending and a great lesson in acceptance from a very special couple. So then why did I feel so sad?<br /><br />That's a rhetorical question, of course. I am sad that informed and legitimate choice is being denied all over our country. I am sad that the leaders of my profession sit idly by and do nothing to train future doctors in the skills of breech delivery. I am sad that hospitals and obstetricians and committees and administrators discourage a reasonable choice. I am sad that insurers and lawyers, who live symbiotically, continue to be the medical decision makers in America. I am sad that when I take rare and deserved time off there is essentially no one to cover me. And, I am sad that this wonderful couple could not experience what they wished for&nbsp;and may now have to deal with the whole VBAC problem next time. I am sad and I am angry. And you all should be, too.&nbsp;&nbsp; Dr. Stu<br /><br /><br />Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com2tag:blogger.com,1999:blog-553033253431866006.post-34460237482350905652013-08-14T20:47:00.001-07:002013-08-15T13:52:22.695-07:00Revisiting The Vaccine QuestionThe to vaccinate or not to vaccinate controversy is far from ended despite a recent statement from the CDC based on an Institute of Medicine (IOM)&nbsp;review that concludes, "the evidence favors rejection of a causal relationship between thimerosal–containing vaccines and autism". I have seen this statement repeated in many recent news items including one in USA Today yesterday. (That just doesn't sound right....USA Today yesterday). I do not profess to have any expertise on this subject other than what I hear and read. Which means I am as confused as you are since the truth does not seem as black and white as the IOM would have us believe. I also, do not think there is any conspiratorial process going on between big Pharma and big Government. <br /><br />So, when asked my opinion recently by a client I was happy to be able to refer them to Jennifer Margulis' new book, "The Business of Baby". Its subtitle talks of what doctors won't tell you and what companies try to sell you and how to determine what's truthful. She presents an extremely well researched and referenced discussion without a personal agenda. Vaccines have performed miracles in the 20th Century, eradicating polio and small pox and minimizing risks from a variety of illnesses from mumps to measles to tetanus. When I traveled to endemic areas I did not hesitate to get vaccinated for yellow fever. <br /><br />But, as will all aspects of life and, as I have related to pregnancy, there is nothing that is risk free. In my career I have seen a case of Guillain-Barre Syndrome related to a routine vaccine. We know that if the threat of a small pox epidemic from bioterrorism were ever to occur that the vaccine would save millions of lives but a few people would have an allergic reaction and die. Because of our ridiculously litigious American society this predictable and medically acceptable risk would result in lawsuits and has scared so many small pox vaccine manufacturers that only one company remains. Not having the capability of having&nbsp;this vaccine mass produced could be devastating. But I digress.<br /><br />Whether to vaccinate or not is a personal decision that each of us has to make for ourselves and our children. What I can say is that in healthy women I see no reason to give universal hepatitis B vaccine to a newborn as is the policy in many hospitals. Always ask about this one. It makes absolutely no sense in families who are not active hepatitis B carriers. And almost every pregnant woman is routinely screened for this. Measles, mumps, Rubella, chicken pox and such options as Guardasil for HPV and the flu shot are never mandatory so do your own research as to the pros and cons. (One article out of Japan has shown that high doses of daily Vitamin D has been more effective against the flu than vaccination. Reminder: This study does not end that debate, either.)<br /><br />I will end this blog with one last example of the rigidity of the academic-medical model taught to most pediatricians. A story related to me by one of my current pregnant clients and one that I hope most pediatricians would abhor. While searching the area for a supportive pediatrician she asked his position on routine vaccination. He stated that he recommended the standard vaccine regimen but that he would still accept her baby into his practice if she chose not to. This sounded most reasonable until he added that if she chose not to vaccinate her baby that he and his associates would only be available for her phone calls during business hours. He would not care for her baby after hours and on weekends should her baby become ill! Seriously, that is what she was told and I believe her.&nbsp;Off to the emergency room with you! As I think about it I am still shaking my head. How does a person say something like that? Does it not seem a bit unethical to that physician? It would be much more honorable to suggest she go elsewhere. I guess this is the new ethics and there is no vaccine against it. Caveat Emptor!Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-72031633027350043812013-08-02T22:12:00.001-07:002013-08-02T22:12:18.239-07:00DrStusPodcast.com<span class="userContent"><div class="text_exposed_root text_exposed" id="id_51fc90b5725267927453975">Ok, so many of my colleagues have noted that I always have an opinion and usually a strong one and a relevant one. They say, and I agree, that I should get out there more and advocate for the good things we do to counter so much of the blov<span class="text_exposed_show">iating that goes on from those against reasonable ideas and choices in birthing. Finally I have taken this advice to heart. It is with excitement and a big smile that I am announcing the creation of my very own podcast with original name of Dr. Stu's Podcast with Brian Whitman at <a href="http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.drstuspodcast.com&amp;h=7AQFizOT_&amp;s=1" rel="nofollow nofollow" target="_blank">www.drstuspodcast.com</a> <br /><br /> Brian is my friend and an accomplished radio personality currently on morning AM radio 870 in Los Angeles and brings his expertise and wit to the show. We discuss timely medical issues and current events. No topic is off limits from the medical world to politics to current events and, of course, LA Kings hockey. Its an informative, informal conversation and banter so come join us. Your support, as always, is appreciated.<br /><br /> Listen online or download for free on iTunes as Dr. Stu's Podcast. The first 3 episodes are up. I will be adding at least 2 new ones every week. Please pass it on, give it a high "5" ranking. Comments and questions are welcome at drstuspodcast@gmail.com</span></div></span>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-72825024304085351322013-07-29T10:10:00.000-07:002013-07-30T08:35:22.418-07:00Truth v. EDA, Preparing Ourselves Part 1This is a longer version of a letter to the editor I had published in the AJOG in response to an opinion piece by a physician&nbsp;and ethicist who has previously stated his dislike for all things home birth. Should a&nbsp;home birth antagonist whose name shall not be spoken quote these opinions as fact in some future presentation, say in Hawaii, maybe in the end of September then it will be good to have honest, coherent counter arguments. Hope this is helpful,&nbsp; Dr. Stu<br /><br /><div align="center" class="MsoNormal" style="margin: 0in 0in 10pt; text-align: center;"><b style="mso-bidi-font-weight: normal;"><span style="font-size: 12pt; line-height: 115%;"><span style="font-family: Calibri;">Redefining Ethics. Truth or Tyranny?</span></span></b><o:p><span style="font-family: Calibri;">&nbsp;</span></o:p></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">In a recent <strong>opinion</strong> piece published earlier this year in the AJOG, “Planned Home Birth: The Professional Responsibility Response”, Chervenak, et al(1) argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 selling points: <span style="mso-bidi-font-weight: bold;">patient safety, patient satisfaction, cost effectiveness, and respect for women’s rights. “{The Authors}</span> provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.” Most of what followed in the rest of his article was&nbsp;neither inductively or reductively logical.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;">As to point 1, patient safety</b>, he says, “Maternal and fetal necessity for transport during labor is <b><i>often</i></b> impossible to predict.” Home birth women by definition are cherry picked for their health. They are allowed to labor as nature intended without interventions. In experienced hands, transport is <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">rarely</i></b>“impossible” to predict. He states the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. He continues his argument against home birth in America by presenting safety data from South Australia, a system that has no resemblance here.<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="mso-bidi-font-weight: bold;"><span style="font-family: Calibri;">He summarizes his anti-safety position this way: “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs. hospital have c/section rates of 6% and 24% respectively (2). By the author’s very own words then, the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible.<o:p></o:p></span></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;"><b>As to point 2, patient satisfaction</b><span style="mso-bidi-font-weight: bold;">, he assumes the high rates of transport undercut the raison d’etre of planned home birth. He cites a Dutch study from 2008 showing persistent levels of frustration for up to 3 years in 17% of transported women. Conversely, that would seem to imply an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of American women with successful home birth vs. hospital birth, but none was made. His solution of supporting “homebirth-like” environments in the hospital setting, sadly, shows a complete lack of understanding of mammalian birth.<o:p></o:p></span></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;"><b>As to point 3, cost effectiveness</b><span style="mso-bidi-font-weight: bold;">, he cites minimal savings in cost comparison data from Britain. Again, the author is using foreign data from a country with single-payer, socialized medicine when a simple Google search easily produces reliable American cost comparison data. This tactic is most concerning in its dishonesty. The cost of a typical home birth here is about a third of that in hospitals. Savings over a cesarean birth approach 85% (3). When c/section rates approaching 35% in the hospital setting are factored in the cost savings is significant.<o:p></o:p></span></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;"><b>Finally, as to point 4, respect for women’s rights</b><span style="mso-bidi-font-weight: bold;">, Dr. Chervenak makes the classic straw man argument. </span>He avoids altogether using the beneficence based model of ethics which, as with VBAC, supports a woman’s reasonable choice (4). <span style="mso-spacerun: yes;">&nbsp;</span>Instead he states, “From the perspective of the professional responsibility model, insistence on implementing the <b>unconstrained</b>rights of<span style="mso-spacerun: yes;">&nbsp; </span>pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine.” But home birth advocates don’t support unconstrained rights or rights based reductionism. Dr. Chervenak has created a whole new theory of ethics, “professional responsibility ethics”, which in his opinion trumps beneficence based ethics and respect for patient autonomy. <o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><span style="font-family: Calibri;">Skewed evidence, selection bias, straw men and anecdotes do not equal data but that is what is presented by the authors as an ethical argument against home birthing. This group of well credential authors has written an article that is more propaganda than evidence based opinion. They might as well have said, ACOG thinks home birth is very, very bad and asked us to make up an argument on their behalf.<o:p></o:p></span></div><br /><div class="MsoListParagraphCxSpFirst" style="background: white; margin: 0in 0in 0pt 0.5in; mso-list: l0 level1 lfo1; text-indent: -0.25in;"><!--[if !supportLists]--><b style="mso-bidi-font-weight: normal;"><span style="line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 10.0pt; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">1.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span></b><!--[endif]-->Chervenak, FA, et al. Planned Home Birth: the professional responsibility response.<span style="mso-spacerun: yes;">&nbsp; </span><span style="font-family: &quot;Arial&quot;,&quot;sans-serif&quot;; font-size: 10pt; line-height: 115%; mso-fareast-font-family: &quot;Times New Roman&quot;;"><span style="display: none; mso-hide: all;"><input name="EntrezSystem2.PEntrez.PubMed.Pubmed_ResultsPanel.Pubmed_ResultsController.ResultCount" type="hidden" value="1" /></span><span style="display: none; mso-hide: all;"><input name="EntrezSystem2.PEntrez.PubMed.Pubmed_ResultsPanel.Pubmed_ResultsController.RunLastQuery" type="hidden" /></span></span><a href="http://www.ncbi.nlm.nih.gov/pubmed/23151491" title="American journal of obstetrics and gynecology."><span style="color: windowtext; font-family: &quot;Arial&quot;,&quot;sans-serif&quot;; font-size: 10pt; line-height: 115%; mso-fareast-font-family: &quot;Times New Roman&quot;;">Am J Obstet Gynecol.</span></a><span style="font-family: &quot;Arial&quot;,&quot;sans-serif&quot;; font-size: 10pt; line-height: 115%; mso-fareast-font-family: &quot;Times New Roman&quot;;"> 2013 Jan;208(1):31-8<o:p></o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="background: white; margin: 0in 0in 0pt 0.5in;"><span style="font-family: &quot;Arial&quot;,&quot;sans-serif&quot;; font-size: 10pt; line-height: 115%; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p>&nbsp;</o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin: 0in 0in 0pt 0.5in; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2; text-indent: -0.25in;"><!--[if !supportLists]--><b style="mso-bidi-font-weight: normal;"><span lang="EN" style="mso-ansi-language: EN; mso-bidi-font-family: Calibri; mso-bidi-font-size: 12.0pt; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">2.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span></b><!--[endif]--><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; mso-ansi-language: EN; mso-bidi-font-weight: bold; mso-fareast-font-family: &quot;Times New Roman&quot;;">Journal of Midwifery &amp; Women’s Health </span><a href="http://onlinelibrary.wiley.com/doi/10.1111/jmwh.2013.58.issue-1/issuetoc"><span lang="EN" style="color: windowtext; font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;">Volume 58, Issue 1, </span></a><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;">pages 3–14, January/February 2013<o:p></o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;"><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; line-height: 115%; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p>&nbsp;</o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin: 0in 0in 0pt 0.5in; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2; text-indent: -0.25in;"><!--[if !supportLists]--><b style="mso-bidi-font-weight: normal;"><span lang="EN" style="mso-ansi-language: EN; mso-bidi-font-family: Calibri; mso-bidi-font-size: 12.0pt; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">3.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span></b><!--[endif]--><a href="http://transform.childbirthconnection.org/resources/datacenter/chargeschart/statecharges/"><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;"><span style="color: blue;">http://transform.childbirthconnection.org/resources/datacenter/chargeschart/statecharges/</span></span></a><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p></o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;"><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; line-height: 115%; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p>&nbsp;</o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin: 0in 0in 0pt 0.5in; mso-add-space: auto; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2; text-indent: -0.25in;"><!--[if !supportLists]--><b style="mso-bidi-font-weight: normal;"><span style="mso-bidi-font-family: Calibri; mso-bidi-font-size: 12.0pt; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;"><span style="font-family: Calibri;">4.</span><span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal &quot;Times New Roman&quot;;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span></span></b><!--[endif]--><a href="http://www.medscape.com/viewpublication/1164"><span style="font-size: 12pt;"><span style="color: blue; font-family: Calibri;">The Hastings Center Report</span></span></a><span style="font-size: 12pt;"><span style="font-family: Calibri;">: “The Ethics of Vaginal Birth After Cesarean”, Sonya Charles </span></span><a href="http://www.medscape.com/viewarticle/767504_3"><span style="font-size: 12pt;"><span style="color: blue; font-family: Calibri;">http://www.medscape.com/viewarticle/767504_3</span></span></a><span style="font-size: 12pt;"><span style="font-family: Calibri;"> <o:p></o:p></span></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin: 0in 0in 0pt 0.5in; mso-add-space: auto; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2;"><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p>&nbsp;</o:p></span></div><br /><div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0pt 0.5in;"><span lang="EN" style="font-family: &quot;Times New Roman&quot;,&quot;serif&quot;; font-size: 12pt; line-height: 115%; mso-ansi-language: EN; mso-fareast-font-family: &quot;Times New Roman&quot;;"><o:p>&nbsp;</o:p></span></div><br /><div class="MsoNoSpacing" style="margin: 0in 0in 0pt;"><span style="font-family: Calibri;">Stuart J. Fischbein, MD FACOG</span></div><div class="MsoNoSpacing" style="margin: 0in 0in 0pt;"><span style="font-family: Calibri;">Medical Director, Sanctuary Birth &amp; Family Wellness Center</span></div><div class="MsoNoSpacing" style="margin: 0in 0in 0pt;"><span style="font-family: Calibri;">Los Angeles, CA<o:p></o:p></span></div><br /><div class="MsoNormal" style="margin: 0in 0in 10pt;"><o:p><span style="font-family: Calibri;">&nbsp;</span></o:p></div>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-32163926230677455742013-07-01T17:51:00.001-07:002013-07-03T09:26:58.795-07:00A Letter to SacramentoDear California Representatives:<br /><br /><br />I am writing to express my support for the independent practice of midwifery in California and the reasonableness of the choice of home birth. I am a practicing obstetrician, trained at Cedars-Sinai Medical Center, board certified in 1989, a Fellow of ACOG for more than 20 years and co-author of the book, “Fearless Pregnancy, Wisdom &amp; Reassurance from a Doctor, a Midwife and a Mom”. The American College of Ob/Gyn (ACOG) frequently does not represent the majority of its members when it takes a position, and their motivation is not always patient centered. A recent paper published in their own journal reported that 2/3rd of their practice guideline bulletins are based on Level C evidence.(1) Level C evidence, by definition, is not based on the best science and represents only consensus opinion. Truth and ethics should be everyone’s overriding concern. Consensus is frequently assumed to be based on truth when, in fact, it often is not. <br /><br />Requiring licensed midwives who assist California women with the reasonable choice of home birth to have supervision from obstetricians who are reluctant to do so or are prevented from doing so by their malpractice policy, without first mandating physician supervision in the same law, is essentially a de facto way to eliminate home birth without lawmakers having to overtly come out against choice. I have worked with both Certified Nurse Midwives and Licensed Midwives over the last 27 years as a back-up physician, supervising physician, direct employer, and in collaboration assisting pregnant women with delivering their babies both in the hospital and home setting. This experience makes me uniquely qualified over my academic and administrative colleagues to give perspective to this debate. I am hopeful that what I have to say will cause you to take a moment to reconsider long held positions about the very nature of human birth.<br /><br />Licensed midwives (LMs) are highly educated, dedicated and nurturing specialists trained in the art and science of normal birth. Physicians are trained as specialists in abnormal or problem pregnancy. LMs spend an hour at each prenatal visit, which allows them to use their expertise in preventative care. Physicians are limited by the medical model to short prenatal visits and are experts at treating disease. Normal pregnancy is not a disease and my physician colleagues do not receive adequate training in normal birth and, therefore, fail to recognize the natural mammalian process of birth. I am certain that a great degree of the friction between these professionals comes from a lack of understanding of what midwives do and how they are trained and the perpetuation of the myth by organized medicine that they are somehow substandard. <br /><br />My experience with midwives has shown me that they want the best for their clients and are not anti-medical zealots. They seek consultation and transport when appropriate. Ideally, both midwives and physicians would benefit if the supervision requirement was removed altogether and transport was made less stressful. For one of the large concerns of physicians is their vicarious liability as a “supervisor.” Malpractice tort reform would be a benefit to all of California’s health professionals but until that day comes the supervision requirement provision should be removed to protect doctors willing to support midwives and possibly allowing for more to come forward. This might make access to choice for California woman more available and that is a good thing. The countries with the best statistics have home birth supported by midwives and the smoothest collaboration with physicians and hospitals for transport. It is in this area that California has failed.<br /><br />Medical ethics dictate that patient autonomy and decision-making is to be respected. And not all patients who are given unbiased and true informed consent should be expected to reach the same decision. Physicians have a fiduciary duty and an ethical obligation to discuss the risks and benefits of all reasonable options. In the skewed argument against the safety of home birth the benefits are never discussed. And the counseling given by doctors almost never reflects equally on the safety and risk of birthing in the hospital. The assumption that hospital birthing and the high rate of medical interventions resulting in a 33% cesarean section rate is safer than home birth for low risk mothers should be challenged. A very large and recently published Dutch study in the prestigious British Medical Journal showed home birth of properly selected women to be safer than hospital birth.(2) Women who have been given true informed consent may well choose a home birth and a midwife as the best option for their family. Sometimes, due to restrictive hospital policies or complete bans on certain evidenced based reasonable options, a woman’s choice of a home birth is all she has as in the cases of a vaginal birth after cesarean and breech birth.<br /><br />I would also like to bring your attention to the argument often given by physicians with contempt for home birth transports because of the occasional bad outcome. Almost all transports from a home birth are for the common issues such as pain relief and exhaustion. All too often the term transport is equated with emergency and that is simply not the case. While it would be wonderful if bad things never happened we should learn from history that trying to legislate absolute safety is impossible and only leads to one size fits all policies which are ethically incompatible with patient autonomy. And while a bad outcome in a home birth gets spread all over the internet, a similar bad outcome in the hospital is hushed up and protected by a veil of confidentiality and HIPPA regulations. Hospitals are not always the safest place to be and certainly not the most nurturing and any honest obstetrician can relate numerous disasters, some preventable and some not, that occurred under the watch of an obstetrician and labor and delivery staff. Hospitals and newborn intensive care units can do wonders when needed and my intention would never be to diminish that. However, we must begin to rethink how we look at normal birth and a woman’s free exercise of all reasonable choices and that is where your leadership is most needed.<br /><br />In summary, I am hopeful that you will take these points into consideration when you deliberate. Home birth and licensed midwifery are reasonable options and therefore ethically sound. While collaboration between doctors and midwives in many western countries has led to better outcomes and statistics the United States continues to lag way behind. Putting our midwives at the mercy or pleasure of reluctant obstetricians is not a constructive idea. Home birth is here to stay. It is a choice many women want and restricting access to the best professionals through medically unfounded legislation will not serve our citizens well. Collaboration and congenial consultation and transport are what is needed. Please allow licensed midwives the freedom to practice and remove the burdensome obligation of direct physician supervision. The status quo only leads to fear and mistrust because of the overwhelming legal concerns facing every doctor forcing them to make decisions that do not put patients first. I would relish the opportunity and be delighted to discuss any aspect of this issue with you, your distinguished colleagues and any members of the medical community holding an alternate point of view.<br /><br />Sincerely,<br /><br />Stuart J. Fischbein, MD FACOG<br />Home Birthing Specialist<br /><br /><br /><br />1: Wright JD et al. Scientific Evidence Underlying the American College of Obstetrics and Gynecologists’ Practice Bulletins. Obstetrics &amp; Gynecology, September 2011; Volume 118; No.3; Pages 1-8<br /><br />2: de Jonge A, et al. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. BMJ 2013;346:f3263 doi: 10.1136/bmj.f3263 (Published 13 June 2013)<br /><br />Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-60687036649313203542013-07-01T17:31:00.003-07:002013-07-01T17:48:57.496-07:00Legislative Alert - AB 1308Greetings to all of you and hoping this finds you and your families well and expecting of a fun summer. I am writing to ask your help in fighting a provision in a bill currently making its way through the California Senate that could severely affect the ability of licensed midwives to practice in the state. AB 1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. It has already been passed by the state assembly and is, in part, sponsored by ACOG. The physician supervision provision has been in the statute since 1993 but has never been enforced because it has previously been seen as unworkable. Most physicians are either unwilling to supervise or are prevented from doing so by their malpractice insurance carrier and/or a hostile hospital administration. <br /><br /><br /><br />AB 1308: http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml;jsessionid=5c82f256d9253d2e4326c4312ddf?bill_id=201320140AB1308<br /><br /><br /><br />Last Thursday, Adeola Adeseun, the attorney for CFAM (California Families for Access to Midwives) and I met with the aide to state Senator Ted Lieu in Redondo Beach. It is his committee that is currently reviewing the bill. The Senator was in Sacramento but we had a very productive meeting with his aide, Veronica, for over an hour. We need to send a lot of emails over the next 24 hours to senator.lieu@senate.ca.gov <br /><br /><br /><br />They need to briefly state their support for licensed midwifery, the choice of home birth and then give a little anecdotal story about their experience. Positive tone is preferred but those who had issues with transport, hospital staff and physician reception can also speak up. They should reference AB 1308 and their concern that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. We would prefer they do away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons. My good friend and associate, Howard Mandel, MD, felt that another analogy might be more appropriate. Family practice physicians often have far less training in pregnancy and birth than a midwife and yet, once licensed and credentialed, are able to practice their trade without supervision. Like midwives, they rely on appropriate consultation. Consultation, not supervision, makes sense. Striking the supervision requirement altogether in the bill would also benefit obstetricians by removing the vicarious liability that some fear when supportive of a local midwife. <br /><br /><br /><br />Can you please take a moment to email the Senator today? senator.lieu@senate.ca.gov <br /><br /><br /><br />Also, can you bombard your contacts, friends and supportive family, especially if they live in the 28th district but any will do, and ask them to send an email to their state senator? <br /><br /><br />It is really important to get this out today. <br /><br /><br />Below are a few logical and passionate letters written by some wonderful people. I can’t thank them and you enough for the support shown for the reasonable choice of licensed midwifery as an option for the women of California.<br /><br /><br /><br />Dear Senator Lieu, <br /><br />I am writing in support for licensed midwifery, and the right for a choice of home birth. I have learned of Assembly Bill 1308 and that if passed and enforced, it would make it a violation of law for a midwife to practice without physician supervision. That provision is completely impractical and unnecessary, as a licensed midwife is fully capable of providing the support needed for the natural delivery of a baby without having a physician present.<br /><br /><br />I am the mother of two young boys ages 6 and 2. The birth of my first son in June 2007 was a delivery by C-section at Santa Barbara Cottage Hospital after a 30-hour labor due to what the hospital staff determined was "failure to progress." There were no medical issues with me or my baby other than I had been in labor "too long" and I was convinced to have a C-section to give birth to my baby. Fortunately, everything went well and I had a healthy baby boy weighing 6 lbs., 10 oz. A few years later when I found out I was pregnant again, my only birth options where I live in Santa Barbara was to have a repeat C-section, which I did not want to endure again, knowing that my body was fully capable of a normal vaginal birth. No doctors, hospitals, or midwives in Santa Barbara were able to provide me support for a VBAC (Vaginal Birth After Cesarean). To my great fortune, I learned of Dr. Stuart Fischbein who has a practice in Camarillo that would support a VBAC home birth with a midwife present. I had a successful home birth of my second son in April 2011 weighing 7 lbs., 14 oz. after only a 4 1/2 hour labor. Dr. Fischbein and the midwife, Karni Seymour-Brown, were present along with my husband, my parents, and my older son. It was beautiful, it was happy, and it was safe. It wasn't just safe because Dr. Fischbein was there, although he is a well-skilled and knowledgeable medical doctor, but I trusted and knew my body could do it, and I was also supported by the knowledge and nurture of the midwife, Karni. Before I had children, home birth sounded like a radical idea to me, but after becoming educated about it, and about my ability to have the right to choose the birth experience that I wanted and was good for me and my baby, I have realized that home birth is the most natural and beautiful way to bring a child into this world. There is of course a time and a need for medical intervention and transport to a<br /><br />hospital in certain situations, but that is rare, as are the situations that would arise to cause the need for a transport. Midwives know just as well when medical intervention and transport to a hospital is necessary, therefore requiring a physician to be present is unnecessary. I have experienced first-hand the wonderful care, support, and wisdom that a midwife provides to a mother before, during, and after birth, and I fully support the practice of independent midwifery. I encourage you, and everyone to do the same.<br /><br /><br />I am concerned about AB1308 enforcing physician supervision of a home birth with a licensed midwife, as the practicality of that does not make sense. A midwife is able to provide full support for a home birth without the need for a physician to be present. Access to this reasonable choice in California to have a home birth with a midwife would be limited with AB1308 in place. Please consider doing away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.<br /><br />Sincerely, <br />Briana Villasenor<br />Santa Barbara, CA<br /><br />Senator:<br /><br />As the father-in-law of a State licensed midwife, I believe I can speak with some authority on the requirement of AB 1308 to make physician supervision mandatory for home births by midwife.<br />As my daughter (in-law) completed the rigorous training required by the State of California to qualify for her certification I asked the questions you are no doubt pondering as you consider your vote. Is the training sufficient? Please, if this is not something you can answer in the affirmative, take a close look at the program the State requires midwives to master. Not just complete, but master. There is a comprehensive test involved here, as well as sworn statements by supervising and qualified midwives of hundreds of hours of hands-on experience.<br /><br />Is there reasonable back-up in the event of a problem beyond the scope of a midwife’s expertise? I do not know the law, but I have spoken to my daughter about my concern. She told me that as the pregnancy progresses she makes contact with the future mother’s doctor and with the hospital the mother would use in case of emergency. Further, she told me that she makes certain emergency transport is available if it is needed. Nothing—nothing—if left to chance. Be assured that no responsible midwife wants a surprise if she has to seek the assistance of a physician. My daughter does not do this to boost her own ego. She is totally caring, devoted to the safe delivery of the child and the health and well being of the mother. The instant a delivery goes outside her comfort zone; she will have the mother transported to a hospital waiting with all required information.<br /><br />I have a close friend who years ago delivered two children some years apart. I talked with her at some length about those deliveries. The first child was delivered in the same manner as I was. She was in a surgery, she was a patient, and there were masked nurses and a doctor. The labor was a bit slow so she received an injection to speed things up. The doctor used a scalpel. She recalled it being cold, sterile, and not at all fun. <br /><br />Her second child was delivered at her home in Fresno under the supervision of a midwife. I spoke with her the next day. She was up, feeling fine, very happy, and eager to tell me the details of the delivery, mainly that the experience took place pretty much at her own direction. She was able to assume a position that was most comfortable for her. She was able to choose the music—yes, music. She asked for and was given a cup of tea. Her husband, of course, was present and assisted her with the midwife’s gentle direction. In short, the second birth was pleasantly memorable, unlike the first, which she told me she tried to forget.<br /><br /><br />The State of California has in place a system which works—works for mothers, for children, for fathers. The State, in it wisdom, has given healthy, responsible adults the right to a birth experience of their choosing while insisting on well trained, licensed professionals to assist. For the State to insist on the direct supervision of a physician over the midwife is to increase cost, needlessly consume physician time, inconvenience all concerned, especially the mother and the father (partner). Given the safeguards presently in place, this legislation is not unlike erecting a speed bump—a BIG speed bump—on a smooth roadway where everyone is smiling an obeying the laws.<br /><br />Respectfully,<br />Christopher Burnett<br />Mariposa, CA<br /><br /><br /><br />Hello Senator, <br /><br />My name is Brooke Kochel and I'm writing to in support of the midwives of California. I'm lucky enough to have had 2 midwives care for both my pregnancies. It was the most proficient, knowledgeable and compassionate healthcare I have ever received. And giving birth at my home near LA 3 months ago with licensed midwives was the safest I've ever felt. <br /><br />I am also a Certified Professional Midwife and understood the level of competence of this group of women, at The Sanctuary Birth and Family Wellness. I was trained as a midwife in the state of Texas, where physician supervision is not required. It was the general consensus there that California was way behind the times to be limiting midwives ability to practice and women's ability to choose who cares for their bodies. I attended hundreds of births in Texas, witnessed normal complications and saw competent midwives firsthand. Their outcomes where outstanding, better than the physicians when low risk births were compared. <br /><br />I had my first baby in Arkansas. I remember the day my midwife told me I had to go to an OB for 2 visits. I felt belittled and that my decisions about my own body were being undermined. I was mad that the government had interfered with this private, personal decision. I felt hurt, scared and anxious knowing that the social climate was unfavorable in this small town. I felt defensive because I knew the physicians were uneducated about midwifery much less supportive of it. I was questioned, scorned, put on hold for long periods of time while the doctor's office figured out "what to do with me". I had to plead with many doctors’ offices to take me, see me. My midwife told me there were no doctors that would voluntarily see me. My only choice was to be seen at a public health clinic that the state set up for low income citizens. I somehow felt that society had shunned me for making what I thought was an outstanding health choice for my unborn child. In the end, an OB saw me as a favor to a friend. Her practice had a regulation to not allow their OBs to see midwives clients when they got wind of it. I wanted to share this story so you understand the social and emotional ramifications of this law. Clients of The Sanctuary are lucky enough to have Dr Fischbein, but many are not. <br /><br />If you support midwives needing supervision then it's like supporting a form of inequality. <br /><br />Thank you for hearing my voice. I assure you it's the voice I've heard a hundred times firsthand from my midwife clients and the group of educated families I surround myself with here in LA. <br /><br />Feel free to contact me.<br /><br />Brooke Kochel<br />Topanga<br /><br /><br /><br />Good morning Senator Lieu, <br /><br />I am writing you this morning to express my overwhelming support for Midwives to practice in California. I am a 38 year old teacher who chose to use a midwife for my prenatal care and the births of all 3 of my children. I cannot say enough about the positive experience I had throughout my pregnancy, delivery and postpartum care. Both of my licensed midwives, Leslie Stewart and Beth Cannon, provided me with exceptional care. Their care went above and beyond the care of any obstetrician. I know this because I saw a licensed obstetrician concurrently during my second pregnancy with twins. <br /><br /><br />My midwife, Beth Cannon, would spend over an hour with me at each appt. She would help me with my nutrition, exercise, my stress level, and coaching me on how to incorporate my new babies into my already existing family. She answered all of our questions, took time examining me and the babies and prepared me and my husband for the birth of our twins. She was never rushed and always very thorough. As a result, my babies were born healthy and without complications. Dr. Stewart Fischbein, OB, was also at the birth of my twins and provided me with concurrent pre and postnatal care.<br /><br /><br />During this pregnancy I also saw, Dr. Rusalna Kadze, OB. Her care was very different from that of my midwife. At each appointment I saw her for less than 5 minutes. She never discussed nutrition, my stress level, or asked me any questions about how I was doing emotionally. On a few occasions, she didn't even measure the babies.<br /><br /><br />During both of my pregnancies I had a back-up physician, should anything arise and I needed to be transported to a hospital. My midwives always took the upmost care to make sure that I would be cared for and the babies would be safe in any situation. My husband and I felt extremely confident in our decision to have home births because we knew our midwives were working with the support of licensed obstetricians. We never needed to transport, but if we had, I am fully confident that my midwife would have, without hesitation.<br /><br /><br />I feel extremely fortunate that I was allowed a choice when choosing how and where to birth. I would not have had this experience without my very dedicated, knowledgeable, patient, loving, supportive and trained midwife. I am asking that you do your part to help keep midwifery legal in California so that many other women and families have the CHOICE on how and where they birth their children.<br /><br /><br />Thank you for listening.<br /><br />All the best, <br />Jennifer Cole<br />Home birth Mother<br /><br /><br /><br />Dear Senator Lieu,<br /><br />I write in support of licensed midwifery and the choice of home birth. I had a simple pregnancy without complications and a straightforward delivery at my home attended by a midwife 5 1/2 years ago. I was glad that safe, legal home birthing is an option in California and hope it will remain so. I am concerned that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. I would prefer to do away with the physician supervision clause altogether in much the same way that chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.<br /><br />Please amend AB1308 to exclude the requirement of physician supervision.<br /><br />Thank you, <br />Vanessa Frank Garcia<br />Ventura, CA<br /><br /><br /><br />Senator Lieu:<br /><br />I am writing to express my concern regarding the above-referenced bill and how it affects a woman's right to choose her practitioner and model of care for childbirth.<br /><br />I am an attorney and six years ago I gave birth in a birth center with the supervision of two highly competent midwives. While they had physician backup, I never met the physician and never needed to. I realize this is not always the case but my personal knowledge of the practice of these two midwives is that they are competent and when physician assistance and hospital transfer has been required, it has been accomplished.<br /><br />My understanding is that physician backup is already required but not enforced and that the current bill will strengthen this provision effectively making it more difficult for women to choose midwifery over obstetrics when giving birth. Like chiropractors and acupuncturists, midwives are skilled medical professionals and requiring backup of a physician is a slap in the face to the professionalism of the practitioners. The licensing of midwives should be sufficient to ensure qualified practitioners, as in the case of chiropractors and acupuncturists, two professions that I have also elected to use.<br /><br />I have professional experience that has enlightened me to the fact that the general medical community and more particularly the obstetric community is hostile toward midwives so it is difficult to find any physician willing or able to backup midwives without fear of reprisal from hospitals and insurance carriers.<br /><br />I strongly urge you not to take away the choice of medical care that is the right of all mothers. <br /><br />Best Regards, <br />Sandy Lipkin<br />Sandra Lee Lipkin, A Law Corporation<br />Ventura, CA <br /><br />Dear Senator Lieu –<br /><br />I am writing to you to express my concerns over a provision in Bill AB1308 that could severely affect the ability of licensed midwives to practice in the state of CA. AB1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. This requirement for physician supervision would effectively limit the birthing choices for many women in the state. <br /><br />Having a licensed midwife as one of the options available for women and families to choose is important as both a personal and public policy decision. I am not an advocate for, nor an opponent against, any specific type of birth option, but I do strongly believe that a woman should be allowed to make those choices that are right for her family, her baby, and herself. This includes not only hospital births with a doctor or midwife, but also births in birthing centers and home births with the support and care of a licensed midwife. <br /><br />I delivered my first child in a hospital setting under the care of a physician who respected the decisions I had made for my labor and my son’s birth: no interventions, no epidural, the freedom to choose a birth position, bonding time immediately after birth, and rooming-in with my son. I was fortunate to have a physician and hospital who respected those choices. <br /><br />When I discovered I was pregnant again, my husband and I were thrilled. When we discovered that I was pregnant with twins, we were doubly thrilled – but also terrified. Most doctors and hospitals across the state (and country) have very specific protocols in place for twin deliveries, including requiring an epidural and delivering in an operating room. Additionally, few doctors either know how to deliver a breech baby or are allowed to do so by their insurance or hospital: my otherwise wonderful physician from my first child’s birth was one of those doctors. If both babies were not head-first (<50 a="" be="" c-section.="" i="" labor="" of="" pregnancies="" present="" prior="" required="" this="" to="" twin="" undergo="" way="" would=""><br />I began to evaluate my options, because being forced to have a potentially biologically unnecessary C-section was terrifying for me. A birthing center or home-birth with a midwife was out: being pregnant with twins automatically deemed my pregnancy “high-risk”, despite all signs pointing to a normal and healthy pregnancy … with an extra baby. I was very fortunate to find a physician who will attend home births. He and a licensed midwife (or, in my case, a licensed midwife and her assistant) come to provide support – medical and emotional – at a woman’s home, where she is able to deliver in the way that she desires, surrounded by whatever and whomever gives her comfort. And that was exactly my experience: my twins were successfully delivered at home, happy and healthy, and I could not be happier with the decision I made to choose that option for myself and my family. <br /><br />I know that my case was very outside of the norm inasmuch as I required and was able to have a physician present at my homebirth. Under normal homebirth circumstances, a licensed midwife and her assistant would be the ones to whom a woman would turn. I am not aware of any other physician in the state who does what my doctor did, so if AB1308 passes, it will effectively force women who do not want a hospital birth to either go without the support and expertise of a licensed midwife or it will force midwives to risk losing their licenses and livelihoods in order to attend a homebirth. Neither of these options is acceptable. <br /><br />Women and families should, within sound medical guidelines, be able to exercise any and all options for the birth experience they choose to pursue: hospital, birth center, or homebirth; intervention-heavy or natural. This is a choice that should not be denied any family, and the requirement for physician supervision of a midwife in this bill effectively does just that. <br /><br />I urge you to do away with the physician supervision clause altogether in order to continue to provide choice surrounding birthing options for women and families in the state of California. <br /><br />Sincerely,<br /><br />Elizabeth A. Nack<br /><br /><br />Good morning Senator Lieu, <br /><br />I have recently become aware of the new provision AB1308 that is making its way through the California Senate. It is my understanding that this new provision could severely affect the ability of licensed midwives to practice in the state and if passed would make it a violation of law for a midwife to practice without physician supervision. Senator I cannot tell you how much of a step backwards this would be to women's health care. Midwives have been in practice for hundreds of years because of their never wavering support of those who they humbly serve. My mother and aunts were born by that fine tradition of midwifery and so was my daughter Eva Victoria Fleming. I chose to have my daughter at home with a midwife after having my son at UCLA Santa Monica with a physician. This is considered one of the best hospitals with some of the very best physicians and if I could do it over I would have had a midwife for both pregnancies and births. The amount of care, understanding and willingness to help were incredible. I was able to express concerns as if talking to an older wiser grandmother/aunt, where as calling to speak with my son's physician I often found myself speaking with the nurse after leaving a few messages. <br /><br />My home birth cost our insurance significantly less than my birth at UCLA. The care given by Karni and Dr. Fischbein were unparalleled to the UCLA doctors. My contractions started at 10am and everyone was at my home by 1. I was guided through one of the toughest days of my life by two angels. My husband had already been through one birth but he was amazed by the detail and care given by these two professionals. My daughter Eva was born at 5:45 that day and I was never rushed or pushed to give her over so someone could take down weights or measurements. As both Karni and Dr. Fischbein had been a part of my birth from start to finish they could see how strong this little girl was. In contrast, my son's doctor literally ran in as I was getting ready to push. I was told to "blow air" so we could wait a little longer for her to arrive. At home my daughter was weighed and measured a few hours after the birth without a timetable and then she was handed to my husband as I was tenderly and respectfully cared for. I was bathed, fed, and generally "put back together". Dr. Fischbein and Karni did not leave my house and my side until 12 o'clock AM. Not because I was an emergency or that I may have been some possible liability but because it is a mark of whom they are and what they do. Dr. Michel Odent, OB/GYN - "We are completely lost and we have forgotten to raise the most simple questions. What are the basic needs of women in labor? The fact that midwives have disappeared is a symptom of the lack of understanding of the basic needs of women in labor."<br /><br />Please let's work to keep these wonderful people an option for my daughter's children and for the future generations to come. Thank you.<br /><br /><br /><br />Sincerely, <br />Victoria Pinero Fleming <br /><br /></50>Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com2tag:blogger.com,1999:blog-553033253431866006.post-54162889987863140892013-06-12T10:43:00.000-07:002013-06-13T19:46:33.720-07:00The Tale of Two Transports: Trials, Tribulations & Happy EndingsHome birthing has its admirers and its detractors. We all know this. There is all too often a lack of respect by overzealous advocates of either side towards the other. My unique experience living in both worlds has shown me that for several reasons, most of them emotional but some of them understandable, those that oppose home birthing want to bully the other side into submission. Through oppression of supportive physicians and self-serving, ethically questionable policies they make it very difficult for the home birth practitioner and client. And once again they are taking their “safety” argument to the legislature to try to mandate physician supervision of licensed midwives even when we all know that most obstetricians are not interested in supervising or are restricted by their malpractice insurance policies from doing so. Thus, many midwives will become illegal in California if this is allowed to become law. Too often there is a blurring of the lines between elective transport and emergency transport. To the on-call obstetrician the knee jerk idea of a homebirth transport is the train wreck. But to most of us in the homebirth world we understand the elective transport is nearly always for the same reasons that patients who plan a hospital birth come in for, only just a bit later in labor. Pain relief, exhaustion and inadequate progress are by far the most common reasons. What makes these women wanting rest, hydration and an epidural more “toxic” and any different from the 90% of women who get these things in the day to day practice of the average obstetrician anyway is simply their preference of home and midwife. Some will say that these patients are unknown to them and therefore high risk. But that argument is specious for most obstetricians practice in large groups these days or they become laborists and so often have no acquaintance or historical relationship to the laboring woman. They will then argue that they can’t be sure these transports had adequate, if any, prenatal care despite records in hand. In reality, most of these women have had better prenatal care from their midwife than any obstetrician can possibly give and my experience tells me they are almost always better educated. But old habits, even misguided ones, are hard to break by those who find no reason to break them. Enter a truly uplifting story of two very different obstetricians and their wonderful deeds of this past week. A testimony to the old adage that truly great men who do extraordinary things will often be despised. Courage is doing the right thing in the face of strong opposition. These two wonderful souls stand out in their compassion, humbleness and willingness to individualize care to patient desires using reasonable choices, true informed consent and sound medical practice. R is a 24 year old, 5’ 9” primipara at 39 weeks who was in active labor for 16 hours. Despite many alternative attempts to rotate her baby he remained occiput posterior. She eventually reached her limit of exhaustion and pain tolerance at 7 cms. My usual back up physician at Cedars-Sinai was away so I put out a few calls to colleagues and was rewarded by two offering to accept her in transport. This may seem a simple thing but I am lucky in that I have choices for back-up when so many of my midwife colleagues are struggling in that arena as discussed above. They drove the 5 minutes over to Cedars while I drove separately. It had been awhile since I have had to transport so I was not quite prepared for the administrative and regulatory onslaught that followed. When I arrived, security would not let me in because R had not yet been admitted. It took a call to the charge nurse to bypass the woman guard with no eye contact to let me in. Upon arriving upstairs R was moaning loudly with every contraction while the nurse was attending to a laundry list of computer data entries, most of which were irrelevant to the medical necessity of an epidural. Admitting wanted the husband to sign all kinds of forms without reading them while R signed a consent form to be treated document between contractions that legally can’t mean anything when a person signs under such duress and pain. Dad refused to sign anything until his wife got her pain relief. A lesser man would have just signed but he knew his rights and pointed out a poster that clearly complied with the EMTALA statues that said “We cannot refuse treatment to anyone!” His point being, treat her first and then we can review documents. And despite much behind the back eye rolling and sighing they actually did. She got her IV and epidural, which still took over an hour, before she had her name band or lab results. Once comfortable, the cascade of interventions began and baby gave all of us a few gray hairs but Dr. C was amazingly patient and trusting of his knowledge of labor and fetal heart patterns. R rested for about 90 minutes and then was feeling a lot of pressure. Dr. C checked her and found the head at plus 2 station but still OP and almost completely dilated. He then used his obstetric skills learned long ago. Putting his hand inside he reduced station, manually rotated the head to transverse and had her start to push. The cervix was reduced and she delivered over an intact perineum after 4 contractions! Baby M weighed in at 6 pounds 15 ounces. That cute little pipsqueak would have easily delivered if not for the persistence of his occiput posterior positioning. Sadly, in most other modern day obstetrician’s hands they may not have been greeted by a wonderfully accepting man and that little pipsqueak would most likely been born by cesarean section. We were all so grateful that there was an experience obstetrician who was trained in a different era in the skills that separate them from today’s obstetric surgeons. J is a 34 year old, 5’ 6” Ventura County primipara at 41 weeks who went into labor the very next day. Her labor was strong and with the support of 2 marvelous doulas, Tracy & Tasha, she was doing great. After about 10 hours of 4 minute strong contractions J asked to be examined. Her sounds were consistent with early transition however her exam was only 2 cm./-1 and 40% effaced and, again, occiput posterior. Over the next 8-10 hours she remained at 4 cm with her cervix getting much more swollen. Despite her heroic effort to this point it was clear to all it was time to transport for an epidural and what follows. Our original backup plan was to go to a LA hospital with supportive backup but they did not want to drive that far and because she worked at the local hospital she knew her previous OB. Dad called and he told them to go to the ER and just tell them to use his name. He said there was no reason to call ahead. So we packed up and all met at the ER. While sitting in the waiting area in a wheelchair the litany of questions began. Now, 2 days in a row for me makes a pattern. It is clear that administration rules the roost as paperwork comes before humanity. One particular question and response from the worker behind the bullet proof glass really stuck with me. It was 5:30 in the morning and J answered that she had ruptured her membranes 6 hours earlier. The woman’s response was so typical of the indoctrination to the one size fits all medical model, “Why did you wait so long to come in?” To those who only see medical birth this is their norm. The question, the timing of it and the tone from the person asking it were so inappropriate and lacking in social skills but we said nothing. In about ten minutes we were on our way up to labor and delivery. Exhausted and in pain with contractions every 3-5 minutes J was, once again, subjected to consent forms and to an even longer laundry list of electronically generated, mostly irrelevant questions unrelated to her immediate need. (Tattoos? LMP? Family History?) And a plethora of questions that were all answered on her prenatal records which I brought with us but which were out at the desk being copied and stamped and posted in the chart but not in the room available to the nurse. I also learned that since I did not have the actual lab report on her negative Group B Strep that hospital protocol states she has “unknown” Group B strep status and therefore antibiotics were ordered (but could be refused). The hand written results and my presence were obviously not good enough for their risk managers but unnecessary antibiotics were fine. Ouch! Next, the charge nurse came in to tell us that her admitting doctor did not want to take her and was passing her off to the on-call doctor. This was odd to me since they had a relationship and it was 6 AM already but it turned out to be the most fortuitous event of the day. For the doctor that was on call was likely the only one within 30 miles that would have allowed J the wonderful outcome that ensued. But I must digress for one last moment. We arrived at the ER at 5:30AM. She came for exhaustion and pain relief. She got her epidural about 7:20AM. That’s an hour and 50 minutes of pretty obvious suffering due solely to the administrative bureaucracy. She was begging for her epidural and all the wonderful nurses could say was that things were moving as fast as they can. It must be so hard for a caring nurse to watch that day in and day out. Tracy says she sees it 5 times a month. No one raises a stink for fear of retribution. There us little humanity in big institutions and it can only get worse. J got comfortable and moved slowly going from 4 to 5 to 6 cm over the next 10 hours. Baby A was doing great, however, but even so it would be the rarest of obstetricians at a hospital with a nearly 40% c/section rate to allow her to crawl along like this in violation of Friedman’s Curve. Coming on 36 hours of labor and 24 hours of ruptured membranes modern obstetricians would become impatient, label this “dystocia or FTP” and proceed to a surgical birth. But Dr. W so honored this families wishes and followed evidence based medicine combined with knowledge of fetal heart patterns to allow her to labor. Sometime after 1AM the next day she was complete and although almost numb was able to push her baby out in 5 contractions at 8 pounds 7 ounces. Her 40 hour labor ended as it should with good collaboration and obstetric practice and joy all around. Will Dr. W get peer reviewed for going off the reservation? Possibly, but he did the right thing. When I think of where my profession was and now is I get very sad. When I see attempts at bullying women and physicians by special interest groups like ACOG and the CMA I get angry. When my experience and wisdom have taught me that informed choice of options and not restriction of options under the façade of safety or the bias of economics are our right I get motivated. These stories of strong women, educated choice and wonderful support and collaboration deserve our attention. Californians need well trained midwives and these midwives and the women they serve deserve the support of our doctors and lawmakers and not their derision. My greatest admiration, almost to tears, goes out for these two women, their families and to the 2 very special doctors who still remember the humanity of our calling. Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com4tag:blogger.com,1999:blog-553033253431866006.post-16327996593034351992013-06-01T11:06:00.002-07:002013-06-01T11:06:39.142-07:00The Impatience to Early Ruptured MembranesOnce again data comes out that may contradict longstanding thinking. Certainly, there is reasonable questioning of the practice of rapid induction for ROM prior to active labor. Strongly suggest reading this article brought to my attention by my midwife colleague, Heather S. <a href="http://midwifethinking.com/2010/09/10/pre-labour-rupture-of-membranes-impatience-and-risk/">http://midwifethinking.com/2010/09/10/pre-labour-rupture-of-membranes-impatience-and-risk/</a> Some will scoff that this comes from a website called Midwife Thinking. I have gotten used to the knee jerk ridicule given to alternative sources by my colleagues in academia. But it is interesting that even the "prestigious" journals have lately had an abundance of published studies that are counter to the longstanding habits of the medical model. I, personally, have found the Cochrane reviews to carry validity and represent solid thinking. Old habits die hard but when they are questionable by reasonable alternatives or just plain wrong, die they must. Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-38166041406170847042013-04-20T11:33:00.001-07:002013-06-01T09:10:35.370-07:00Labor is not a Toothache!From curvewire.com: Kim Kardashian Wants C-Section Posted by Johnny Robish on April 10, 2013 - 10:18pm..... <i>“Kim Kardashian Wants C-Section: It’s being reported that pregnant Kim Kardashian wants to give birth by C-section as soon she’s 8-months pregnant because she wants her life back. And since Kanye is a musician, I would assume it’ll most likely be a “Middle-C” section.”</i> ..... I was at a dinner party last night in celebration of the recent homebirth of twins in Santa Barbara, CA. During a lovely evening we discussed a lot of topics and the subject of Ms. Kardashian’s choice came up. This blog is not about bashing her obvious narcissism but her choice did produce a dialogue about labor pain. I have given this subject a lot of thought during my metamorphosis from hospital based to home based practitioner. Since epidurals and narcotics are not available at home we rely on other methods to deal with pain. Movement, water, hypnosis, massage and strong support are beneficial and work well for many laboring women. The key is that these things help cope with the pain but don’t remove it. To understand why coping but not eliminating pain is important we need to ask ourselves why labor is painful in the first place. I mean, if we believe in evolution why wouldn’t the pain of labor evolve away since natural selection usually eliminates those things that are detrimental to the survival of the species. There is, of course, the biblical Garden of Eden explanation but let me put that aside for the moment. Just suppose labor pain is not detrimental but is beneficial. I give credit to my colleague, Aleks Evangelidi, LM, for her insight in this regard........ Anyone who has ever had a toothache or a kidney stone will argue there is no benefit to the pain other than to let us know something is wrong. Painkillers are a godsend in these circumstances. But labor is not a toothache and it is time to look at the pain of labor in a different light. All mammals have labor and all mammals have labor pains. The onset of labor contractions usually build slowly but eventually become quite painful lasting 40-60 seconds followed by 2-3 minutes of relief. The mammalian body responds to this pain by releasing its own narcotics and neurotransmitters that nature designed just for that purpose. Endorphins and enkephalins are the body’s natural opiates. Oxytocin release produces warmth and attachment responses and adrenaline helps the body cope with stress and possibly spaces out the next contraction allowing time for rest and recovery. And don't forget Cortisol, which orchestrates all sorts of needed stress responses including blood sugar modulation. It really is a beautiful cocktail that nature has designed just for this purpose............ When a laboring woman is not allowed to cope with pain as nature designed it is easily understood why hospital epidural rates approach 90%. Having to stay flat in bed so continuous fetal monitoring (CFM) can occur does not allow for the natural desire and ability of mammals to move about in labor to diminish discomfort and use their own pain stimulated cocktail. And so, modern obstetrics encourages epidural use to eliminate pain and modern women think this is a good choice because to them: Labor Pain = Toothache........ It gets back to the saying about the long habit of not thinking something wrong gives it the appearance of being right. Nature is pretty smart. And a toothache does not have a baby inside but a pregnant woman does. And when a woman undergoes the stress of labor so does her baby. Her body’s response to pain releases that cyclical cocktail and those substances certainly cross the placenta. And just maybe all those neurotransmitters and hormones that help mom deal with the pain and stress of labor help her baby cope as well. For after 9 months of sitting comfortably in the womb suddenly everything that baby has ever known is changing. Labor has to be stressful and even painful for the baby and the suddenness of delivery by c-section even more so. Mom’s natural opiates, oxytocin and adrenaline clearly serve a purpose in assisting her baby in this transition. Denying the baby these substances through the commonplace use of epidurals or scheduled c-sections is counter to nature’s design. Babies are little sponges absorbing every experience and forging new and sometimes permanent neural pathways that will be used in the future. Altering labor has to mean altering this process as well. I was never taught this way of thinking in residency and in my 31 years as a physician I have never seen this discussed in a grand rounds or an academic journal and yet it is so common sensical. Modern medicine needs a bit of humbling and as we are beginning to discover when you mess with Mother Nature you inevitably get something not intended........... The process of labor is painful for a reason and that reason just may be how it benefits the baby’s transition to extra-uterine life. Women are too often told that the pain of labor need not be endured. And while modern anesthesia is also a godsend and epidurals have a place in some labors, obstetricians need to rethink their unconcerned attitude towards its ubiquitous use. Especially in those cases where they scoff at the woman with a birth plan that states an avoidance of pain medicine. Allowing laboring women the freedom to move about and use other pain coping mechanisms might just be doing future generations a favor. Once again it boils down to informed consent. If Ms. Kardashian still wants her unnecessary c-section so she can have her life back after reading this blog then that is her choice and should be respected. I am willing to bet she has never been taught about or thought of birth in this way. Dr. F Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com6tag:blogger.com,1999:blog-553033253431866006.post-60585474096836022692013-03-31T11:12:00.002-07:002013-03-31T12:04:10.772-07:00Cesarean Section & Newborn ImmunityWith the proliferation of unnatural birth by cesarean section in the United States it is only to be expected that new data on the consequences of this intervention will be forthcoming. We have now had about 30 or more years of rising “elective” cesarean section rates in the U.S. which gives us a good petri dish from which to see good scientific evidence of its effects. One of the negative effects seems to be the rise in respiratory ailments in neonates and children. In a recent review by Cho and Norman, (<a href="http://www.ajog.org/article/S0002-9378(12)00857-5/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology">Cho CE , Norman M. Cesarean section and development of the immune system in the offspring . Am J Obstet Gynecol. 2013;208:249–254</a>), they conclude: “Recent epidemiological studies provide evidence that elective cesarean section (CS) is associated with aberrant short-term immune responses in the newborn infant, and a greater risk of developing immune diseases such as asthma, allergies, type 1 diabetes, and celiac disease. However, it is still unknown whether CS causes a long-term effect on the immune system of the offspring that contributes to compromised immune health.” They conclude that more emphasis should be placed on discussion and counseling amongst professionals and childbearing women. In the same issue of the AJOG is a corresponding article by Romero and Korzeniewski from Wayne State University that discusses the likely causation of Cho’s findings. <a href="With the proliferation of unnatural birth by cesarean section in the United States it is only to be expected that new data on the consequences of this intervention will be forthcoming. We have now had about 30 or more years of rising “elective” cesarean section rates in the U.S. which gives us a good petri dish from which to see good scientific evidence of its effects. One of the negative effects seems to be the rise in respiratory ailments in neonates and children. In a recent review by Cho and Norman, (Cho CE , Norman M. Cesarean section and development of the immune system in the offspring . Am J Obstet Gynecol. 2013;208:249–254), they conclude: “Recent epidemiological studies provide evidence that elective cesarean section (CS) is associated with aberrant short-term immune responses in the newborn infant, and a greater risk of developing immune diseases such as asthma, allergies, type 1 diabetes, and celiac disease. However, it is still unknown whether CS causes a long-term effect on the immune system of the offspring that contributes to compromised immune health.” They conclude that more emphasis should be placed on discussion and counseling amongst professionals and childbearing women. ">http://www.ajog.org/article/S0002-9378(12)02261-2/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology</a>I strongly suggest reading the full article as it goes into depth explaining the importance of microbial exposure at birth and its correlation to the newborn’s immune response. They cite a sentinel work by Hugo Lagercrantz and Theodore Slotkin that emphasized the importance and adaptive value of intrapartum stress in their seminal article “The ‘Stress’ of Being Born.” In it, “The authors described 4 main transitions that occur at birth: (1) emergence from an aquatic environment where oxygen is acquired through the placenta to a dry environment in which respiratory exchange occurs through the lungs, (2) change from a warm environment in which the fetus has a temperature that is 1 degree higher than the mother on average to a cooler environment at room temperature, (3) moving from a continuous supply of nutrients through the placenta to intermittent feeding in the neonatal period, and (4) going from a sterile bacterial environment to the establishment of the neonatal microbiome (eg, skin, respiratory tract, gut). Lagercrantz and Slotkin's views have gained relevance with time and are now buttressed by a considerable body of work suggesting that the microbiome plays an important role in the developing immune system.” It would seem the body of evidence is beginning to weigh heavily that there are consequences to the route of birth. For those of us that support vaginal birth options this comes as no surprise. Nature does have common sense sometimes. The ethics of informed consent should imply that obstetricians include this information when counseling patients on the RISKS and benefits of an elective cesarean section. One final article in the same edition of the AJOG takes a different tack. Authors Lynch and Iams state: “we fear that their (Cho, et al) limited review of a very complex literature leads the reader to a naïve conclusion: that the cesarean procedure itself might be bad for infants and children.” <a href="http://www.ajog.org/article/S0002-9378(12)02262-4/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology">http://www.ajog.org/article/S0002-9378(12)02262-4/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology</a>They take a critical look at the methodology and cannot agree with Cho’s conclusions. It seems they think that prematurity and its effects on the immune system may play a role in skewing the data and that cesarean section cannot be isolated as having a direct role in causation. While I applaud the AJOG for publishing all three of these articles and bringing the problem of a rising cesarean section rate into the limelight, I cannot ignore the contradiction to when the Wax paper was published. If you recall, the Wax paper criticized the safety of home birthing and was immediately adopted as gospel by ACOG and critics of home birth. There was no such corresponding critique of its methodology in the same issue of the Green Journal despite a myriad of cited authors who found great flaws in his methodology and conclusions. Maybe I am overly sensitive but it seems clear that these two articles, one critical of elective cesarean section and one critical of home birthing, are being responded to in different fashions, both of which seem to favor and support the expediency of the current medical model of obstetrics. I mean, here you have compelling data of the risk of surgical birth on newborns and whether or not scientists and researchers believe it fully isn’t it worthy of informing mothers of this research and letting them decide? A peaceful Easter to you. Dr. F Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com3tag:blogger.com,1999:blog-553033253431866006.post-10545003255495920232013-03-17T10:02:00.000-07:002013-03-17T12:12:05.778-07:00Cholestasis & The Rule of Threes!One of the oddities and urban legends haunting the halls of medical schools and centers of learning is the theory that bad things often come in sets of three. It may be years before you see an ectopic pregnancy and suddenly you have three. Months go by and suddenly you have three clients in a week who have abnormal Pap smears. Some of us go a long time without having a set of twins in our practice and, then, there are three in one month. No explanation, probably coincidence, but perplexing all the same. The rule of threes has struck again! This past month in my practice I have three women, two of them with twins, who developed cholestasis of pregnancy. Cholestasis of pregnancy usually manifests itself in the third trimester of pregnancy with the symptom of intense itching usually on the belly. <a href="http://americanpregnancy.org/pregnancycomplications/cholestasispregnancy.html">Cholestasis of Pregnancy</a> Here is a reference to a relatively simple explanation of this disorder which has an incidence of about 1-2/1000 pregnancies. I thought I would use this blog to illuminate some of the research and thought for my colleagues and me. It is rarely predictable and the major theory is that high levels of certain pregnancy hormones slow or block the flow of bile from the gallbladder. This backup then causes some of the bile salts to be absorbed in the bloodstream and eventually deposited in the skin. Diagnosis is usually suspected by the symptom of a rashless itching and confirmed by laboratory testing. Treatment is discussed in the links I have provided and supplemental Vitamin K has been suggested for the mother while pregnant and nursing and for the baby after birth. There are numerous case reports in the literature of bad fetal outcomes from this disorder, and while not the norm, these have led to the suggestion that the treatment for cholestasis of pregnancy at term is delivery. (Not by cesarean section unless for other indications). Here are a few suggested links: <a href="http://www.ncbi.nlm.nih.gov/pubmed/9453428">Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo.</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/18006244?">http://www.ncbi.nlm.nih.gov/pubmed/18006244?</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/16449148?">http://www.ncbi.nlm.nih.gov/pubmed/16449148?</a> <a href="http://www.ncbi.nlm.nih.gov/pubmed/19155945?">http://www.ncbi.nlm.nih.gov/pubmed/19155945?</a> In my practice, so far 2 of the 3 women have been delivered. One set of twins with elevated liver tests was fortunate to have Dr. Wu in Glendale induce her and have a vaginal birth of her vertex/vertex twins. Another was breech and, sadly, had no option of induction so had a primary cesarean section. The third client with twins is still holding on with stable labs, well informed consent and hopes of her home vaginal birth. I hope none of you ever experience this rare problem but am of the philosophy that being well informed is a good thing. Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com1tag:blogger.com,1999:blog-553033253431866006.post-80343078425610932482013-02-24T17:24:00.001-08:002013-03-03T10:21:10.250-08:00Trusting Nature....AgainJust as she had hoped for she began having regular contractions every 15-20 minutes on the evening of her assigned due date. This couple had a history of several recent pregnancy losses and was so happy expecting their first baby. But like most parents in our fear based society they were frightened of what they had read about birth and especially about hospital birthing. Also, mom worked in a health care facility and what she experienced made her wary of western medicine. Mom has a phobia for hospitals and for needles and so sought out the option of home birthing. They had been referred to me by a midwife colleague in her first pregnancy which had ended in a miscarriage. We had spent much time together over the past two years and the trust necessary for a successful birth was the result. As part of our many conversations we discussed the midwifery approach to pregnancy and birth as well as the medical model and the care that resulted was a hybrid of both. My experience with both models of care gave her the confidence to overcome some mental and physical obstacles. She had to take medication through the first trimester because of her previous miscarriages. In the medical model she would have been labeled “high risk”. But once the milestone was passed and her medication stopped she was as normal as any other mother. Many physicians would have continued to carry the high risk label with all the subsequent fear and over-testing that comes with such a label. There is no doubt in my mind that doing so would have written a much different story of her labor and birth. Add to that the positive group B Strep carrier state and frightening stories of babies gone awry that so often accompanies that scenario and a perfect storm for interventions would be brewing. Through the night her contractions increased in intensity and came every 4-5 minutes. We spoke just after midnight and again at 3:30AM and just after dawn. I cancelled my day in the office as she lived about 50 miles from there and waited. After sunrise and as the morning passed her contractions spaced out. I have become acutely aware of the power of the higher brain over the primitive brain. My lectures about the mammalian nature of birth make the understanding of distractions and the effect on labor so obvious and clear. This family is highly educated and as mentioned tends to think too much on the “what ifs” and so I was not surprised that as the day wore on labor malingered with her contractions coming every 7-20 minutes all day long. My midwife and I stopped over about 7:00PM to take some vital signs and give reassurance and suggestions for comfort, rest and patience. It was likely that if she was not given these things that she would be up another full night and eventually become exhausted. We put her to bed after a warm shower and some fluids and suggested that she not try to walk her baby out. She was able to get some rest and sleep through the night and awoke on the third day still with regular but infrequent contractions and a bit of bloody show. I went to work this time at my much closer office feeling a bit foolish for missing the previous day. But understanding labor and predicting its course is not a fruitful activity. Trusting it, however, has proven reliable. Gradually, her contractions picked up in intensity and frequency to the point where the next phone call just after 7:00PM came from her husband. For those of us practicing the home birth model the call from the husband is a sure sign of things progressing. Mom is now too inwardly focused to make the call. The birth team arrived at 8PM to loud noises and concerned looks from Grandma and relief from dad. A quick assessment showed all to be as it should be and a requested exam was 7 cm. and still intact. I started an IV which drew loud protests. Reminded of her needle phobia I used a little lidocaine first. 2 grams of Ampicillin were administered and we prepared our equipment while mom walked, paced, sat on the toilet, knelt on all fours supported by her man. Around 10PM her membranes spontaneously ruptured and just before 11PM the incredible urge to push could not be resisted. A gentle exam showed baby to be at +2 station with no cervix left. In less than an hour they were holding their baby in their own bed with emotions of relief and exuberance and joy! Having seen birth in hospitals and birth at homes there is no comparison. To call them by the same name, “birth”, does not do justice to the differences. Just over 48 hours had passed from the time of the first regular contraction. I was confident that labor would progress here in its own time. If not, nothing would have been lost with conscientious observation and eventual transfer of care. I have little doubt that my hospital based colleagues would never have allowed nature to follow its own path. The first morning she would be told to go to the hospital. Here she would have gone through the usual litany of tests, consents, interruptions and indignities. Labor cannot function well in that setting. Her contractions spacing out would have precipitated an IV, CFM and either Pitocin augmentation or AROM, likely the former considering the group B strep status. Unable to move or shower would have meant an epidural and eventual AROM likely with fetal scalp electrode and, of course, NPO. If she made it to complete she would have likely been too numb to push effectively leading to a longer second stage and possible operative vaginal birth and laceration or episiotomy. Who does not believe she had at least a 40% chance of a c/section? There is little if any room in the hospital model for patience and trust in the wisdom of the natural labor process. Now, at home, holding her baby for the first time, no lacerations, placenta out, and husband next to her with her own mother looking on there was this amazing smile on her face. A face that earlier had the look of determination mixed with panic that so often appears in transition. Never separated from her baby and a realization of what she had accomplished, her life and that of her child’s will never be the same. The stories they will tell and the admiration husband will have for wife are so different than they might have been had not the process of labor been respected. My experience and wisdom for understanding the variances of the birth process did not come from books or residency training. It is not something I or any obstetrician can glean from watching hospital birthing. There is too much hustle and bustle and timetables and interruptions and fear in that setting to learn to trust birth. I am so fortunate that my journey has taken this path and that I allowed myself to be open to learning. I and the women I care for are grateful to the midwives and visionaries who have taught me well. Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com2tag:blogger.com,1999:blog-553033253431866006.post-41673337011663379142013-02-01T19:05:00.003-08:002013-02-01T19:05:36.402-08:00Birth Center OutcomesFew words needed from me. Read Tara Elrod's Blog at <a href="http://taraelrod.blogspot.com">taraelrod.blogspot.com</a> and find the full article at <a href="http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full">http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full</a> This is a huge study in both it's numbers and for support of the benefits of the freestanding birthing center option. Always nice when good evidence based medicine supports what we all know to be true. The authors, 2 midwives and a physician from Yale University conclude: This study demonstrates the safety of the midwifery-led birth center model of collaborative care as well as continued low obstetric intervention rates, similar to previous studies of birth center care. These findings are particularly remarkable in an era characterized by increases in obstetric intervention and cesarean birth nationwide.Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com2tag:blogger.com,1999:blog-553033253431866006.post-15842613770694214772013-01-30T09:07:00.000-08:002013-01-30T09:11:41.087-08:00Stage 2 ConsequencesMuch of what passes for legislation these days seems to be feelings based and reactionary. With litte time given to debate or deep thought. As long as it feels good there is no concern whether once implemented it will <b>actually do</b> good. The Affordable Care Act (Obmacare) is the penultimate example of stopping at stage 1 thinking. As Nancy Pelosi so famously said, "You will have to pass the bill to find out what is in it!" Well, think on this! I recently read an opinion piece in the Wall Street Journal titled, <b>"The Doctor's Office as Union Shop"</b> by Dr. David Leffell, a practicing physician and the former CEO of the Yale Medical Group and a professor at the Yale School of Medicine. As you know me by now, I am a critical reader of opinion pieces and pretty much anything that passes as mainstream news these days. It is hard to know what to believe. I could not find any fault, however, in Dr. Leffell’s arguments about what is likely to happen to doctors in the wake of the government takeover of health care thus reducing the once proud sole proprietor into nothing more than a salaried service worker. If you have followed my blog for some time you will find that I am not a fan of the poorly named “Affordable Care Act” for a myriad of reasons. One of which has been the inevitable discouragement of the ambitious and brightest from undertaking the years of commitment and expense it takes to become a physician. Those young men and women who prefer to be shepherds of their destinies and not sheep will look to other opportunities. What will remain are dedicated workers who will prefer defined hours, a better lifestyle and the security of a set salary. While this is not a bad thing in and of itself it is like the proverbial finding of half a worm in an apple. For their employer will no longer be “the self” but will be the government or some big faceless corporate entity dependent on government rules and regulations that define treatment protocols and regulate reimbursement. Dr. Leffell says, <i>“The truth is that physicians are now becoming service workers. They are well-educated and expensive to train, and their decisions have substantial significance in the lives of others. But doctors essentially provide a service, one that cannot be outsourced to India or China……When doctors occupy a service niche like the chambermaid in Las Vegas or the school teacher in Chicago, the expectations and compensation of the physician-worker will be defined in ways that may make the benefits of collective bargaining appear very attractive…… If doctors unionize, that raises an immediate question about their right to strike—the key lever in collective bargaining. That's a question for another day. For now, it's enough to contemplate what will occur when the practice of medicine becomes detached from its past as a profession—when doctors may in time come to see themselves not solely as healers but as workers, units of labor, in a system that is committed to delivering care to the greatest number.” <b></b></i>It is inevitable then, as government inserts itself into the equation, that choice for consumers will decline and services will be rationed. Cost containment will fall heavily on doctors and hospitals. With no relief from threats of malpractice lawsuits and pressure to adhere to artificially set performance standards piled on top of less financial reward we will inevitably see rising job dissatisfaction. And although the expectations of Americans will be that they should get the same quality of care for less money in reality that is not possible. All the micromanaging and theories about efficiency do not take into account what happens in the real world. No longer individual professionals but now salaried workers, likely disgruntled salaried workers, what is to keep physicians from unionizing? Leaders of the dwindling private sector organized labor movement will drool at the prospect of a whole new profession to appeal to. As Dr. Leffell’s concludes: <i>As has happened in other countries that have charted the course we are now on, a new reason for lack of access may at times be: "Office closed, doctors on strike." <b></b></i> Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com4tag:blogger.com,1999:blog-553033253431866006.post-45356816050333970022013-01-09T22:13:00.001-08:002013-01-09T22:13:50.567-08:00Power Point DebutToday the gracious members of the Orange County DASC hosted a gathering and invited me to come and share my thoughts on home birth and a recent opinion piece in the AJOG which took a strong stance against it. It was an educational experience for all of us and I really appreciated the attention and feedback. I talked about logic and ethics and how this opinion article skewed its ethical arguments, applied faulty logic and created straw man arguments in an attempt to vilify home birth and those who support it. We tend to be a headline reading society and rarely have the time or expertise to truly analyze the content in a critical manner. Doing so here led me to the surprising conclusion that ethicists are not always ethical and the editors of the AJOG ought to not blindly accept shameful submissions from well credentialed authors without vetting the data. I would be happy to share or debate my take on this with any inquiring minds. Happy New year! Lets make it a safe and honest one. Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com0tag:blogger.com,1999:blog-553033253431866006.post-12259068927876467392012-12-24T19:11:00.001-08:002013-01-09T21:57:13.142-08:00Dissecting the Ethics of the EthicistMerry Christmas and much hope for a honest and healthy new year in 2013. As I mentioned in a previous blog there was an opinion piece in the American Journal of Obstetrics and Gynecology online version from November by Chervenak with which I took issue. Its titled, "Planned home birth: the professional responsibility response" and is intended to make the argument for health practitioners to use against those who desire or support out of hospital birthing. It would be all too easy for practitioners to read this, consider the source and trust it as gospel. Critical reading of this article, however, shows it to be flawed and biased and even on occasion purposely deceitful. It is deserving of a point by point review and rebuttal but to do so by prose I found too lengthy and confusing. I could not figure how to respond to the AJOG in a letter with an acceptable word count. So, the past few weeks I have been working on a power point presentation which has the ability to present Dr. Chervenak's positions and evidence based counterarguments in a meaningful and comprehensible manner. I intend to begin to offer lectures and gatherings so that this paper does not go unchallenged. Please spread the word to your local groups and let me know if you would like me to come and speak. Ideally, obstetricians uninformed or against home birthing would be a great audience but it would be an honor to present this debate to all interested parties. Warmly, Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com3tag:blogger.com,1999:blog-553033253431866006.post-53603094598874301822012-11-13T23:53:00.001-08:002013-01-09T22:16:32.691-08:00The Battle Against Home Birth Choice EscalatesAnother anti-home birth article was published in this months American Journal of Ob/Gyn. I want to stress that this is an <b>OPINION</b> piece and not a study. I have already seen many news articles that refer to a new "study" out against the safety of home birth. I cannot link it directly but I am certain it will continue to get lots of play from home birth detractors. This one is specifically written to assist obstetricians in developing arguments and reasons not to support the option of home birth. <i><b>Planned home birth: the professional responsibility response.</i> Chervenak, et al. AJOG Clinical Opinion November 2012</b> The positions and arguments presented there are worthy of point by point review in the proper forum. For now, here are some of my quick insights: This is nothing new from Dr. Chervenak. In my opinion he gets lost in his own glow on this subject into which he has put an inordinate amount of time and effort. I am still confused how he places fetal rights above those of the mother in todays society. While I agree that the fetus has rights it would seem the abortion without restriction argument has won the day in the recent election cycle making that argument questionable at best. He cherry picks much of his data and suggests a model of professional responsibility ethics that fits his purpose while excluding the beneficence model he has supported in the past. He still relies on the disputed Wax paper and a lot of data from Southern Australia. I know nothing about southern Australia but I highly doubt it is as filled with proximate medical centers as is Los Angeles County or other large urban areas in America. Quoted rates of transfer from the Netherlands study seem high relative to my own 26 years of experience working with home birth midwives. Nonetheless, a nonemergent transfer, as most of them are, is not a reason to deny a woman the option. I read some of his data and examples and anecdotes and come to completely different conclusions as to the decision process. Clearly, we both have a bias. Chervenak is a bright man who considers his opinions to be truth and unassailable. I do agree with his recommendation that doctors and hospitals become more friendly and nurturing to women and offer a full course of options. Until that day comes, however, there is no place like home as a legitimate choice for some women. Dr. FStuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com5tag:blogger.com,1999:blog-553033253431866006.post-70759410249622741652012-11-13T00:13:00.001-08:002012-11-13T07:05:14.795-08:00Term Breech Trial R.I.P.“Hands off the bum” was the message at this year’s Heads Up International Breech Conference. It was quite a gathering in Chevy Chase, Maryland. I want to express my most sincere gratitude to Robin Guy and her whole team for putting together a marvelous weekend. I attended as a moderator and panelist and feel very fortunate to share the spotlight with luminaries in the field. We were honored to have doctors Anke Reiter from Frankfurt, Germany, Andrew Bisits from Sydney, Australia, Marek Glezerman from Israel, Martin Gimovsky from Newark Beth Israel Hospital in New Jersey, Michael Hall from Colorado and Dennis Hartung from Wisconsin. Midwives Ina May Gaskin, Ibu Robin Lim, Jane Evans and Betty Anne Daviss were amongst a host of experts and educators in the world of breech delivery. It was a marvelous weekend with so many nurturing people supporting the reasonable option of selected vaginal breech delivery. Research was presented from 3 major academic centers that support the safety of vaginal breech as a reasonable and evidenced based choice and putting to rest, hopefully forever, the Term Breech Trial as something to be relied on as a basis for denying the breech option. There seems to be no significant difference in neonatal morbidity between vaginal and cesarean section for breech. There is a greater risk for the mother in this and future pregnancies when c/section is performed. All agreed that a change is needed in education for young physicians and midwives. Reintroducing breech delivery will not be easy as the skill and willingness has waned. We all believe the leaders of our profession including ACOG in the U.S. need to take a more active role in encouraging this movement. Ideally, specialized breech training centers such as exists in Frankfurt, Germany will open up creating the volume needed for interested doctors and midwives to learn the skills. Dr. Reiter presented her and Dr. Frank Leuwen’s techniques of delivering breech babies meeting their selection criteria in the all-fours position. They use MRI to measure the pelvic conjugate as their main criteria for inclusion. Other presenters used more traditional inclusion criteria but all agreed that selected vaginal breech delivery in experienced hands is a reasonable choice with a 60-70% chance of success. As with VBAC, if this option is dismissed by hospitals and doctors then they are wrongly condemning that percentage of women to surgery and the greater risk that incurs. Choice belongs to the informed woman! We were treated to videos and testimonials and birth stories from professionals and from some brave women willing to share their personal histories. Never let it be said that a healthy baby is all that matters. Some of these women still shed tears when they recall their births and how they had to struggle against skewed informed consent and a system that had failed them. We as a profession can do better. A special thanks to my colleague Beth Cannon, LM for her support of my bid to bring breech back to Southern California. And to Kimberley Van Der Beek for taking 4 days away from her family to share her breech experience, speak on two panels and host movie night. Changing old habits, especially those that are bolstered by convenience, economics and liability concerns will not be easy. But honesty and ethics must prevail to maintain the respect our profession deserves. Selected vaginal breech delivery is an evidenced based option that should be honored. This means offering it should attempts to turn the baby fail if the practitioner is comfortable and competent or referral to someone who is if they are not. For it is inevitable that some women will present in advanced labor with the breech presenting. Best we all relearn the skills as to be an obstetrician means more than just being proficient with a scalpel and a pap smear. I look forward to spreading the word and the skill. Thank you Coalition for Breech Birth! Stuart Fischbeinhttps://plus.google.com/101158864951133408418noreply@blogger.com1